Implantable biologic stent and system for biologic material shaping, preparation, and intraocular stenting for increased aqueous outflow and lowering of intraocular pressure

ABSTRACT

A system for preparation of an implant and ab interno insertion of the implant into an eye including a handle having one or more actuators and an elongated shaft having an outer sheath and an elongate member positioned within a lumen of the tubular outer sheath. The system includes a recess sized for holding a patch of material fixed relative to the handle and a cutting member movable relative to the handle and to the recess. The cutting member cuts the patch of material into an implant as the cutting member moves towards a cutting configuration. The implant, once cut, is axially aligned with the lumen of the tubular outer sheath. The inner elongate member is movable relative to the tubular outer sheath to advance the implant into a deployment position in the lumen of the tubular outer sheath for delivery into the eye. Related devices and methods are provided.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of co-pending U.S. patent applicationSer. No. 16/777,648, filed Jan. 30, 2020, which claims the benefit ofpriority under 35 U.S.C. § 119(e) to U.S. Provisional Patent ApplicationSer. Nos. 62/861,900 filed Jun. 14, 2019; 62/897,570 filed Sep. 9, 2019;and 62/943,106 filed Dec. 3, 2019. The disclosures of the applicationsare hereby incorporated by reference in their entireties.

BACKGROUND

The mainstay of ophthalmic surgery for glaucoma is the enhancement ofaqueous outflow from the eye. There are various approaches to suchsurgery, including: 1) ab externo trabeculectomy or shunting, whichrequires cutting the conjunctiva and the sclera to penetrate the eye andprovide a trans-scleral outflow path; 2) ab interno trabecular ortrans-scleral outflow stenting or shunting of aqueous withhardware-based implantable devices or with ablating, non-implantablecutters such as dual-blade and trabectome; and 3) ab internosupraciliary stenting using implantable non-biological hardwareimplants.

Current ab interno stenting devices and methods are based onnon-biological hardware materials such as polyimide, polyethersulphone,titanium, poly styrene-blocks-isobutylene-block-styrene and others.There are significant drawbacks with such non-biological hardware-basedimplantable devices as such devices can lead to major erosion, fibrosisand ocular tissue damage such as endothelial cell loss.

In view of the foregoing, there is a need for improved devices andmethods related to ophthalmic surgery for the treatment of glaucoma.

SUMMARY

Disclosed are methods and devices for lowering, adjusting, or otherwiseregulating intraocular pressure in an eye by way of implantation of aminimally invasive, bio-tissue stent in the eye. In an exampleimplementation, a bio-tissue implant, such as a bio-tissue stent, shunt,or implant, is implanted into the eye such that the stent is at leastpartially positioned in a suprachoroidal, trans-scleral, and/orsupraciliary location in the eye for treating glaucoma. The stent can beimplanted via an ab interno delivery pathway into the eye using adelivery device that is configured for such a delivery pathway. In anexample implementation, the stent assists or otherwise provides fordrainage of aqueous humor from the anterior chamber to a uveoscleraloutflow pathway of the eye. The stent provides a fluid passagewaybetween the anterior chamber and a suprachoroidal space and/or thesupraciliary space. The stent provides a fluid passageway/outflow in twoindependent yet potentially collaborative ways such as by stenting thesupraciliary cleft and by using hydrophilic biologic material thatallows transudative aqueous flow through the material itself. Otherdrainage pathways are considered including Schlemm's canal or via asubconjunctival location.

In an aspect, provided is a system for preparation of an implant and abinterno insertion of the implant into an eye. The system includes ahandle having one or more actuators; an elongated shaft extending in adistal direction from the handle. The elongated shaft having a tubularouter sheath and an inner elongate member positioned within a lumen ofthe tubular outer sheath. The system includes a recess sized for holdinga patch of material fixed relative to the handle and a cutting membermovable relative to the handle and to the recess into a cuttingconfiguration. The cutting member cuts the patch of material into animplant as the cutting member moves towards the cutting configuration.The implant, once cut, is axially aligned with the lumen of the tubularouter sheath. The inner elongate member is movable relative to thetubular outer sheath to advance the implant into a deployment positionin the lumen of the tubular outer sheath for delivery into the eye.

The patch of material can include biologically-derived material suitablefor transplant into the eye. The biologically-derived material caninclude tissue harvested from a donor or from the eye. Thebiologically-derived material can be autograft, allograft, or xenograftmaterial. The material can be engineered tissue. The engineered tissuecan be 3D-printed material suitable for implantation. Thebiologically-derived material can have a permeability and/or firmstructure allowing for aqueous outflow from the eye when the implant cutfrom the patch of material is positioned within a cyclodialysis cleft.The implant cut from the patch of material can be bioabsorbable ornon-bioabsorable.

The implant can include one or more therapeutic agents. The one or moretherapeutic agents can include antiproliferatives, antifibrotics,anesthetics, analgesics, cell transport/mobility impending agents,antiglaucoma drugs, prostaglandin analogues, carbonic anhydraseinhibitors, neuroprotectants, antibiotics, anti-viral agents,antiallergenics, anti-inflammatories, mydriatics, or immunomodulators.

The patch of material can be compressed and/or tensioned before thecutting member is moved into the cutting configuration. The patch ofmaterial can be compressed between two appositional planar surfacespreventing movement during subsequent cutting of the patch of materialwith the cutting member. The patch of material can be tensioned by apair of flexible stretcher legs configured to apply a stretching forceaway from a center line of the patch of material.

The system can further include a cartridge detachably coupled to aregion of the handle. The cartridge can include a base and a cover. Therecess can be positioned within the base of the cartridge. The recesscan be positioned within the handle. The system can further include anaccess door coupled to the handle and configured to enclose the recesswhen rotated to a closed configuration and reveal the recess whenrotated to an open configuration. The access door can be formed of atransparent or translucent material. The system can further includeprojection extending upward from a center line of the recess forming twochannels within the recess on either side of the projection. Theprojection can urge a centerline of the patch of material upward towardthe door. The patch of material can be captured between the projectionand the access door when the access door is rotated to the closedconfiguration relative to the handle. The access door can be configuredto apply tension to the patch of material when the access door is in theclosed configuration. The access door can include an actuator configuredto apply the tension. The actuator can include a pair of flexiblestretcher legs configured to extend into the recess. The pair offlexible stretcher legs can include a first foot that contacts the patchof material on a first side of the center line and an opposite foot thatcontacts the patch of material on an opposite side of the center line.The first foot and the opposite foot can be urged outward away from oneanother as the pair of stretcher legs are urged further into the recessby the actuator stretching the patch of material relative to the centerline.

At least a proximal portion of the elongated shaft can extend along alongitudinal axis. A distal end region of the elongated shaft can beangled away from the longitudinal axis. A distal end region of theelongated shaft can have a maximum outer diameter that is no greaterthan about 1.3 mm. A distal-most tip of the elongated shaft can be bluntto allow for dissecting between tissues of the eye without cutting thetissues. The tubular outer sheath can be a hypotube having an innerdiameter that is less than about 0.036″ to about 0.009″. The implant cutfrom the patch of material can have a dimension that substantially fillsan inner diameter of the tubular outer sheath.

The tubular outer sheath can be coupled to a first actuator and theinner elongate member is coupled to a second actuator. The firstactuator can be positioned on an lower surface of the handle configuredto proximally retract the tubular outer sheath and the second actuatorcan be positioned on an upper surface of the handle configured todistally advance the inner elongate member. Distal advancement of theinner elongate member can urge the implant distally through the lumen ofthe tubular outer sheath into a primed position near a distal openingfrom the lumen of the tubular outer sheath. Proximal retraction of thetubular outer sheath while the inner elongate member remains stationaryrelative to the handle can unsheathe the implant from the elongatedshaft to deploy it within the eye.

The tubular outer sheath can be an introducer tube movable through alumen of a fixed outer tube. The inner elongate member can be movablewithin the introducer tube. The introducer tube can be more flexiblethan the inner elongate member and the inner elongate member can be moreflexible than the fixed outer tube. The inner elongate member can takeon the shape of the fixed outer tube when retracted proximally and relaxback into a curved shape when extended distally out of the outer tube.The introducer tube can conform to the curved shape of the innerelongate member when both the introducer tube and the inner elongatemember are extended distally out of the outer tube.

In an interrelated aspect, provided is a cartridge for use with a systemfor preparation of an implant and ab interno insertion of the implantinto an eye. The cartridge includes a base having an upper surfacedefining a recess sized and shaped to receive a patch of material to becut into an implant. The cartridge includes a cover movably coupled tothe base between an open configuration and a closed configuration. Thecover has a lower surface arranged to appose the upper surface of thebase when the cover is in the closed configuration. The cartridgeincludes a cutting member movable relative to the base and to the recessinto a cutting configuration. The cutting member cuts the patch ofmaterial into the implant as the cutting member moves towards thecutting configuration. The implant, once cut, is axially aligned with alumen of a tubular outer sheath for delivery into the eye.

When the cover is in the closed configuration, the patch of material canbe held fixed relative to the base. When the cover is in the closedconfiguration, the patch of material can be compressed within therecess. The cover can be configured to apply tension on the patch ofmaterial compressed within the recess.

In an interrelated aspect, provided is a method of preparing an implantfor implantation into, and of inserting the implant into, an eye of apatient. The method includes inserting a patch of a material into aproximal portion of an instrument. The instrument further includes acutting member and a distal portion sized for insertion into an eye. Themethod includes cutting the patch with the cutting member to form theimplant. The method includes advancing the implant from the proximalportion of the instrument into a deployment position in a lumen of anelongate tubular member of the distal portion. The method includesinserting the distal portion of the instrument into the anterior chamberof the eye. The method includes positioning the distal portion adjacenteye tissue and deploying the implant from the instrument.

Inserting the patch of the material can include inserting the patch intoa recess in the proximal portion and closing a cover over the recess.The cover can be adapted to engage at least some portion of the patch ofthe material before the cutting. At least a portion of the cover can betransparent. The cover can prevent movement of the patch during thecutting of the patch with the cutting member. The method can furtherinclude tensioning at least a portion of the patch of the materialbefore cutting the patch. The tensioning of the portion of the patch caninclude compressing a first portion and a second portion of the patchand tensioning a central portion of the patch, the central portionlocated between the first and second portions. The central portion ofthe patch can include the implant upon the cutting the patch with thecutting member. Tensioning the portion of the patch can includeactivating an actuator to tension the portion of the patch. Activatingan actuator can include rotating the actuator to tension the portion ofthe patch. The cover can include an actuator, and actuation of theactuator tensions at least a portion of the patch. The method canfurther include inserting the distal portion of the instrument abinterno into the anterior chamber through a corneal incision, while theproximal portion of the instrument remains outside the eye. The materialcan be biologically-derived material suitable for implantation into theeye. The biologically-derived material can be tissue harvested from adonor or from the patient, or autograft, allograft, or xenograftmaterial. The material can be an engineered or 3D-printed materialsuitable for implantation. The implant can include one or moretherapeutic agents.

Deploying the implant from the instrument can result in the implantresiding at least in part between a ciliary body and sclera of the eyeof the patient. The implant can reside between the ciliary body andsclera within a cyclodialysis cleft. The cutting member can include acutting member lumen, a distal opening and a pair of opposed cuttingedges. The cutting can include advancing the cutting member to cut thepatch of the material and capturing the implant within the cuttingmember lumen. The pair of opposed cutting edges can cut the patch in twolocations to separate the implant from a remainder of the patch. Aninternal diameter of the elongate tubular member can be substantiallythe same as an internal diameter of the cutting member lumen. A distalportion of the cutting member can be beveled. The implant can include alongitudinal axis. The longitudinal axis of the implant can remainaligned with a longitudinal axis of the lumen of the elongate tubularmember as the cutting member finishes cutting the patch to form theimplant.

Advancing the implant from the proximal portion of the instrument caninclude pushing the implant out of the cutting member lumen and into thelumen of the elongate tubular member of the distal portion. A distal endregion of the elongate tubular member can be at least one of angled orcurved or flexible. The method can further include activating a firstactuator to tension at least a portion of the patch before the cutting;activating a second actuator to advance the cutting member to cut thepatch after the tensioning; activating a third actuator to advance theimplant into the deployment position; and activating a fourth actuatorto deploy the implant from the instrument, wherein each of the actuatorsis operatively coupled to the instrument.

Positioning the distal portion adjacent eye tissue can includepositioning the implant between the ciliary body and sclera while theimplant remains at least partially inside the lumen of the distalportion. Deploying the implant from the instrument can includeretracting the elongate tubular portion from the implant whilemaintaining the implant's position relative to the adjacent eye tissue.A distal-most tip of the elongate tubular member can be blunt to allowfor dissecting the eye tissue without cutting the eye tissue. Closingthe cover over the recess can include engaging a portion of the coverwith a first portion of the patch to compress the first portion of thepatch and to tension a second portion of the patch.

The details of one or more variations of the subject matter describedherein are set forth in the accompanying drawings and the descriptionbelow. Other features and advantages of the subject matter describedherein will be apparent from the description and drawings, and from theclaims.

BRIEF DESCRIPTION OF THE DRAWINGS

These and other aspects will now be described in detail with referenceto the following drawings. Generally, the figures are not to scale inabsolute terms or comparatively, but are intended to be illustrative.Also, relative placement of features and elements may be modified forthe purpose of illustrative clarity.

FIG. 1 is a cross-sectional view of a human eye showing the anterior andposterior chambers of the eye with a stent positioned in the eye in anexample location;

FIGS. 2A and 2B show example implementations of a trephination devicefor forming a stent;

FIG. 3 shows a perspective view of an example implementation of adelivery device;

FIG. 4 shows a cross-sectional view of the delivery device;

FIG. 5 shows an implementation of a delivery device having atrephination cartridge in an open configuration;

FIG. 6A shows an implementation of a delivery device having atrephination cartridge in a closed configuration;

FIG. 6B is a cross-sectional view of the device in FIG. 6A taken alongline B-B;

FIG. 7 shows a partial view of a delivery device shaft having a patch ofbiologically-derived material extending through cut-out windows;

FIG. 8A is a top-down schematic view of the cut-out windows of adelivery device shaft;

FIG. 8B is a cross-sectional view of FIG. 8A taken along line B-B;

FIG. 9A is a perspective view of an implementation of a trephinationcartridge;

FIG. 9B is a cross-sectional view of the trephination cartridge of FIG.9A;

FIG. 9C is a perspective view of the base of the trephination cartridgeof FIG. 9A;

FIG. 10A is a perspective view of the trephination cartridge of FIG. 9Arelative to a cutting member;

FIG. 10B is a cross-sectional view of the trephination cartridge of FIG.10A with the cutting member partially inserted;

FIG. 10C is a cross-sectional view of the trephination cartridge of FIG.10A with the cutting member fully inserted;

FIG. 11A is a side view of the cutting member of FIG. 9A showing theblades relative to a delivery device shaft loaded with a patch ofbiologically-derived material;

FIG. 11B is a perspective view of the cutting member of FIG. 11A withthe housing removed;

FIG. 11C is a side view of the blades relative to the delivery deviceshaft and cut stent;

FIG. 11D shows a side view of the cut stent primed within the lumen ofthe delivery device shaft;

FIG. 11E is a distal end view of the delivery device shaft having atubular outer sheath and an inner elongate member or pusher;

FIGS. 12A-12B illustrate a distal end region of the delivery device;

FIG. 13A is a top view of an implementation of a delivery device;

FIG. 13B is a bottom view of the delivery device of FIG. 13A;

FIGS. 14A-14B are partial views of the delivery device of FIG. 13A;

FIGS. 15A-15C are schematic views of a stretcher applying tension on apatch of material;

FIGS. 16A-16B are schematic views of a cutter tube cutting a patch ofmaterial;

FIGS. 17A-17B are schematic view of a pusher priming a cut stent withinthe delivery shaft;

FIG. 18A is a top view of an implementation of a delivery device;

FIG. 18B is a bottom view of the delivery device of FIG. 18A;

FIGS. 19A-19B are partial views of the delivery device of FIG. 18A;

FIGS. 20A-20C illustrate a stretcher configured to apply tension on apatch of material;

FIG. 21 is a cross-sectional view of the delivery device of FIG. 18Ashowing the stretcher;

FIG. 22 is a partial view of a cutter tube advanced through the deviceof FIG. 18A;

FIGS. 23A-23D are detailed, partial views of the cutter tube of FIG. 22;

FIGS. 24A-24C are partial, cross-sectional views of the cut stent beingreleased from the delivery shaft if FIG. 18A;

FIG. 25 is a partial, cross-sectional view showing advancementmechanisms for various axially movable components of the device of FIG.18A;

FIG. 26 is a partial, cross-sectional view of a retraction mechanism forthe introducer tube of the device of FIG. 18A.

It should be appreciated that the drawings are for example only and arenot meant to be to scale. It is to be understood that devices describedherein may include features not necessarily depicted in each figure.

DETAILED DESCRIPTION

Disclosed are implants, systems, and methods for increasing aqueousoutflow from the anterior chamber of an eye. As will be described indetail below, ab interno outflow stenting using biological, cell-basedor tissue-based materials provides biocompatible aqueous outflowenhancement with improved tolerability and safety over conventionalshunts. In an example implementation, a biologic tissue orbiologically-derived material is harvested or generated in vitro andformed into an implant, also referred to herein as a stent, using atrephination device or cutting tool. In an implementation, the stent isan elongated body or strip of tissue that does not have an internallumen. Lumen-based devices can be limited by the lumen acting as a tractfor fibrotic occlusion. The stent formed from the tissue is thenimplanted into the eye via an ab interno delivery pathway to provideaqueous outflow from the anterior chamber. The stents described hereincan be used as a phacoemulsification adjunct or stand-alone treatment toglaucoma as a micro-invasive glaucoma surgery (MIGS) treatment.

Use of the terms like stent, implant, shunt, bio-tissue, or tissue isnot intended to be limiting to any one structure or material. Thestructure implanted can, but need not be a material that is absorbedsubstantially into the eye tissue after placement in the eye such that,once absorbed, a space may remain where the structure was previouslylocated. The structure once implanted may also remain in place for anextended period and not substantially erode or absorb.

As will be described in more detail below, the stents described hereincan be made from biologically-derived material that does not cause toxicor injurious effects once implanted in a patient.

The term “biologically-derived material” includes naturally-occurringbiological materials and synthesized biological materials andcombinations thereof that are suitable for implantation into the eye.Biologically-derived material includes a material that is a naturalbiostructure having a biological arrangement naturally found within amammalian subject including organs or parts of organs formed of tissues,and tissues formed of materials grouped together according to structureand function. Biologically-derived material includes tissues such ascorneal, scleral, or cartilaginous tissues. Tissues considered hereincan include any of a variety of tissues including muscle, epithelial,connective, and nervous tissues. Biologically-derived material includestissue harvested from a donor or the patient, organs, parts of organs,and tissues from a subject including a piece of tissue suitable fortransplant including an autograft, allograft, and xenograft material.Biologically-derived material includes naturally-occurring biologicalmaterial including any material naturally found in the body of a mammal.Biologically-derived material as used herein also includes material thatis engineered to have a biological arrangement similar to a naturalbiostructure. For example, the material can be synthesized using invitro techniques such as by seeding a three-dimensional scaffold ormatrix with appropriate cells, engineered or 3D printing material toform a bio-construct suitable for implantation. Biologically-derivedmaterial as used herein also includes material that is cell-derivedincluding stem cell(s)-derived material.

The biologically-derived material, sometimes referred to herein asbio-tissue or bio-material, that is used to form the stent can vary andcan be, for example, corneal tissue, scleral tissue, cartilaginoustissue, collagenous tissue, or other firm biologic tissue. Thebio-tissue can be of hydrophilic or hydrophobic nature. The bio-tissuecan include or be impregnated with one or more therapeutic agents foradditional treatment of an eye disease process.

Non-biologic material includes synthetic materials prepared throughartificial synthesis, processing, or manufacture that may bebiologically compatible, but that are not cell-based or tissue-based.For example, non-biologic material includes polymers, copolymers,polymer blends, and plastics. Non-biologic material includes inorganicpolymers such as silicone rubber, polysiloxanes, polysilanes, andorganic polymers such as polyethylene, polypropylene, polyvinyls,polyimide, etc.

Regardless the source or type of biologically-derived material, thematerial can be cut or trephined into an elongated shape suitable forstenting and implantation in the eye. This trephination process of thetissue can be performed before the surgical implantation process orduring the surgical implantation process. The stent(s) implanted in theeye may have a structure and/or permeability that allows for aqueousoutflow from the anterior chamber when positioned within a cyclodialysiscleft.

FIG. 1 is a cross-sectional view of a human eye showing the anteriorchamber AC and posterior chamber PC of the eye. A stent 105 can bepositioned inside the eye in an implanted location such that at least afirst portion of the stent 105 is positioned in the anterior chamber ACand a second portion of the stent 105 is positioned within tissues suchas within the supraciliary space and/or suprachoroidal space of the eye.The stent 105 is sized and shaped such that the stent 105 can bepositioned in such a configuration. The stent 105 provides or otherwiseserves as a passageway for the flow of aqueous humor away from theanterior chamber AC (e.g. to the supraciliary space and/orsuprachoroidal space). In FIG. 1, the stent 105 is representedschematically as an elongated body. It should be appreciated that thesize and shape of the stent 105 can vary.

The stent 105 can be implanted ab interno, for example, through a clearcorneal incision or a scleral incision. The stent can be implanted tocreate a communication between the anterior chamber AC and thesupraciliary space, the anterior chamber AC and the suprachoroidalspace, the anterior chamber AC and Schlemm's canal, or the anteriorchamber AC and the sub-conjunctival space. In a preferredimplementation, the stent 105 is implanted such that a distal end ispositioned within a supraciliary position and the proximal end ispositioned within the anterior chamber AC to provide a supraciliarycleft. The distal end of the stent 105 can be positioned between otheranatomical parts of the eye.

Conventional glaucoma stenting devices are typically formed ofnon-biological materials such as polyimide or other synthetic materialsthat can cause endothelial tissue damage leading to progressive,long-term, and irreversible corneal endothelial loss. The stentmaterials described herein can reduce and/or eliminate these risks oftissue damage while still providing enhanced aqueous humor outflow.

The stent 105 described herein can be formed of any of a variety ofbiologically-derived materials having a permeability and/or structurethat allows for aqueous filtration therethrough. The stent 105 can beformed of a biologically-derived material that is harvested, engineered,grown, or otherwise manufactured. The biologically-derived stentmaterial can be obtained or harvested from a patient or from donors. Thebiologically-derived stent material can be harvested before or duringsurgery. The biologically-derived stent material can be syntheticbio-tissue created using in vitro techniques. The biologically-derivedmaterial can be stem cell generated or bioengineered. The tissue can begenerated via in situ cellular or non-cellular growth. In an exampleimplementation, the tissue can be 3D printed during manufacture.

The 3D printed tissue can be printed as a larger patch of material thatis then cut at the time of surgery as described elsewhere herein.Alternatively, the 3D printed tissue can be printed to have thedimensions of the final implantable stent. In this implementation, the3D printed material need not be trephined before implantation, but canbe implanted directly. For example, the 3D printed stent can be printeddirectly into a cartridge that is configured to operatively couple withthe delivery device described herein, which is in turn used to deploythe 3D printed stent into the eye. The 3D printed stent can be generatedusing the 3D printing process described in Biofabrication, 2019; 11 (3).

In an example implementation, the stent 105 is made of a bio-tissue. Thebiologically-derived material can be corneal tissue and/or non-cornealtissue. The biologically-derived material may include corneal, scleral,collagenous or cartilaginous tissue. In an implementation, thebiologically-derived stent material can be denuded corneal stromaltissue without epithelium and endothelium that is porous and hashydrophilic permeability to allow aqueous filtration. Thebiologically-derived material of the stent 105 can, but need not beincorporated into the eye's inherent anatomy after placement in the eye.The stent can cause the surrounding tissue to form a pathway thatremains open for an extended period, even after absorption of the stent.The biologically-derived stent material may not significantly absorb orbe incorporated into the eye's anatomy such that the stent 105 remainsimplanted for an extended period of time or indefinitely, as needed.

In other implementations, the stent 105 material may be manufactured ofa complex carbohydrate or a collagen that is non-inflammatory. The stent105 may also be formed of a biodegradable or bioabsorbable materialincluding biodegradable polymers including hydroxyaliphatic carboxylicacids, either homo- or copolymers, such as polylactic acid, polyglycolicacid, polylactic glycolic acid; polysaccharides such as cellulose orcellulose derivatives such as ethyl cellulose, cross-linked oruncross-linked sodium carboxymethyl cellulose, sodiumcarboxymethylcellulose starch, cellulose ethers, cellulose esters suchas cellulose acetate, cellulose acetate phthallate, hydroxypropylmethylcellulose phthallate and calcium alginate, polypropylene, polybutyrates,polycarbonate, acrylate polymers such as polymethacrylates,polyanhydrides, polyvalerates, polycaprolactones such aspoly-c-caprolactone, polydimethylsiloxane, polyamides,polyvinylpyrollidone, polyvinylalcohol phthallate, waxes such asparaffin wax and white beeswax, natural oils, shellac, zein, or amixture.

As mentioned, the biologically-derived stent material can have apermeability or porosity that allows for aqueous filtration forsufficient control or regulation of intraocular pressure. Permeablebio-tissues described herein (e.g. sclera, cornea, collagen, etc.) arepreferred stent materials, however, any bio-tissue, even if impermeable,is considered herein as a potential stent material to serve as astructural spacer that keeps the cyclodialysis open. Preferably, thematerial of the stent can create a gap that allows fluid to flow. Thegap created can run longitudinally along each side of the stent. If thematerial of the stent is permeable, more fluid can pass through thecyclodialysis than if the stent material is impermeable and the fluid isrequired to pass along the outside of the stent. Thus, the materialconsidered herein need not be porous in order to provide the desiredfunction, however, the function can be enhanced by the porosity of thematerial.

Generally, the biologically-derived stent material has some firmnesssuch that it can maintain outflow from the anterior chamber, however, isless stiff than conventional non-biologically-derived polyimide shuntsused in the treatment of glaucoma (e.g. Cypass, Alcon). The stentmaterial may have a sufficient structure to serve as a spacer to propopen a sustained supraciliary outflow. The stent material can maintainits structural height or thickness once implanted within thecyclodialysis such that fluid flow through or around the stent isprovided. Biologically-derived stent material provides advantages interms of biocompatibility, anatomic conformity, and aqueous permeabilitycompared to conventional non-biological materials such as polyimide.Biologically-derived stent material can provide better conformabilityand compliance to the scleral wall and can be less likely to causeendothelial and scleral erosion/loss over time and with chronic eyerubbing and blinking.

In an implementation, the material used to form the stent is provided asan uncut patch of material configured to be manually loaded within thedelivery device at the time of implantation. In other implementations,the biologically-derived material used to form the stent is provided asan uncut patch pre-loaded within the shaft of the delivery device andheld within a trephination device 205 or cartridge. In still furtherimplementations, the stent 105 comes already cut into the shape of thestent pre-loaded in the delivery device shaft 310 or within a cartridgeconfigured to be loaded with the delivery device. The portion of thedevice carrying the biologically-derived stent material (whether pre-cutto a stent size or as the larger patch size) can be packaged in such away that the material is stored in medium or other suitable preservativesolution for the biologically-derived material. In some implementations,the entire device is packaged in a fluid bath or a portion of the devicesubmerged in a separate container prior to attaching it to atrephination device or delivery device at the surgical site.

After the appropriate material has been obtained and prepped, atrephination device can be used to create an elongated stent of apredetermined dimension from the patch of material. As will be discussedin greater detail below, the trephination can be done at the time ofsurgery or prior to surgery. In certain implementations, the stent isformed by 3D printing and can be printed into a desired final dimensionfor the stent or can be printed as a patch of material that is thentrephined at the time of or prior to surgery. The trephination achievedby the devices described herein results in very thin strips of materialthat can be implanted in the eye to provide regulation of aqueousoutflow. The trephination achieved positions the cut implant within aconduit or lumen of the delivery device such that the cut implant may besubsequently delivered from the delivery device without needing toremove or transfer the cut implant from the cutting element into thedelivery tube. The process of trephination can simultaneously or insubsequent actuations load the cut implant into a delivery conduit forimplantation in the eye.

The term “patch of material” as used herein refers to a piece ofbiologically-derived material having a size along at least one dimensionthat is greater than a size of the stent cut from the patch of materialand implanted in the subject. In some implementations, the patch ofmaterial can have a generally square shape and the stent trephined fromthe patch of material can have a generally rectangular shape. Forexample, the patch of material can be about 7 mm wide×7 mm long×0.55 mmthick and the stent trephined from the patch of material can be 0.3-0.6mm wide×7 mm long×0.55 mm thick. The dimensions of the patch of materialand the trephined stent can vary. The patch of material and thetrephined stent can each have the same length and the same thickness,but differ from one another in width. The patch of material and thestent trephined from the patch of material can also have differentlengths and thicknesses. For example, the patch of material can have afirst thickness and the stent trephined from the patch of material havethe same thickness, but when implanted can be folded or rolled into adifferent thickness from the patch of material.

The stent trephined from the patch of material can have a width, alength, and a thickness. In an implementation, the width of the stenttrephined from the patch of material using the trephination devicesdescribed herein can be at least 100 microns up to about 1500 microns,or between 100 microns up to 1200 microns, or between 100 microns and900 microns, or between 300 microns and 600 microns. The stent trephinedfrom a patch of material can have a width of at least about 100 micronsand a width of no more than 1500 microns, 1400 microns, 1300 microns,1200 microns, 1100 microns, 1000 microns, 900 microns, no more than 800microns, no more than 700 microns, no more than 600 microns, no morethan 500 microns, no more than 400 microns, no more than 300 microns, orno more than 200 microns. The length of the stent trephined from a patchof material can vary depending on the location of stent implantation. Insome implementations, the stent has a length that is between 1 mm and 10mm, or more preferably between 3 mm and 8 mm long. The thickness of thestent trephined from the patch of material can be from 100 microns up toabout 800 microns, or from 150 microns up to about 600 microns. In animplementation, the biological material forming the stent can have athickness that is no smaller than 100 microns and no larger than 5 mm.The thickness of the stent can also depend on whether the stent isfolded or rolled upon implantation such that a patch of material havinga thickness of just 250 microns can cut into a stent and the stentfolded at implantation to double the thickness to about 500 microns. Thethickness of the stent can also depend upon what biologically-derivedmaterial is used. For example, scleral tissue or corneal tissue canoften have a thickness of around 400 microns, but following harvest canshrink to about 250-300 microns. As such, a stent cut from a shrunkenpatch of corneal tissue may have a thickness of just 250 microns. Insome implementations, which is described in more detail below, the stentcut from the patch of material is cut so as to substantially fill theconduit through which it is advanced for delivery.

In a non-limiting example, bio-tissue stent has dimensions no smallerthan 0.1 mm and no larger than 8 mm in any direction and a thickness ofnot smaller than 50 microns and not larger than 8 mm. In a non-limitingexample, the stent is about 6 mm in length by 300-600 microns wide by150-600 microns thick. The trephination can be no smaller than 1 mm andno larger than 8 mm in any direction. In a non-limiting example, thetrephined tissue has dimensions of 100-800 microns in width and 1 mm-10mm in length. It should be appreciated that multiple stents may bedelivered to one or more target locations during an implantationprocedure.

The trephining devices described herein provide accurate and precisecutting without wrinkling. The trephining device can incorporate ananterior-to-posterior capture such that the material to be cut is heldfixed on the z-plane preventing movement prior to engaging the tissuewith a cutter. In implementations described in more detail below, thematerial to be cut is held fixed, compressed, and/or tensioned prior tocutting.

FIGS. 2A and 2B show example implementations of a trephination device205. The intraoperative trephination device used to form the stent canbe combined with or removably coupled to a delivery device, such as anapplier/injector for delivery to the implanted location. FIGS. 3-4,FIGS. 13A-13B, and FIGS. 18A-18B show implementations of a trephinationdevice integrated with a delivery device. The trephination devices canbe a cartridge that removably couples to the delivery device as shown inFIGS. 5, and 6A-6B. The cartridge containing the patch of a material canbe coupled to a distal portion of the delivery device as shown in FIG. 5and FIGS. 6A-6B. In this implementation, the cartridge can be removedfrom the delivery device prior to deployment of the stent to the eye.The cartridge containing the patch of a material can alternatively becoupled to a proximal portion of the delivery device. In thisimplementation, the cartridge need not be removed prior to delivery ofthe stent into the eye and the stent cut from the patch of material canbe deployed from the cartridge coupled to the delivery device without aseparate step.

The trephination device is configured to cut or otherwise form thebiologically-derived tissue or patch of a material having a firstcontour or shape (e.g., a wider, square sheet or patch of material) intoa second contour or shape (e.g., a narrower, rectangular strip ofmaterial) that conforms to an implantable stent having the dimensionsdescribed herein. The cutting performed using the trephination devicesdescribed herein can involve guillotine, punch, rotating, sliding,rolling, or pivoting blade cutting motion. In some implementations, thecutting is performed orthogonal to the plane of the patch of material.In some implementations, the cutting is performed axially along theconduit of implantation. As such, the axis of trephination can bealigned, within, or parallel to the implantation conduit to allowunimpeded tissue loading and transfer for implantation withoutmanipulating, tearing, or damaging the fragile stent tissue. Thetrephination process can be preceded by a tissue fixation step whereinthe biologically-derived tissue that forms the stent is firmly fixedbetween two appositional planar surfaces to ensure the tissue is notwrinkled or malformed and the subsequent trephination cut is of accuratedimensions. The fixation can optionally provide tension or stretching ofthe tissue within at least one plane to ensure clean cutting through thetissue.

The trephination can be performed along or within a path or conduitformed within the structure, such as within a cartridge, the deliverydevice, or within any other structure. The trephination of the patch ofmaterial can simultaneously or subsequently position the implant withinor aligned with a conduit (e.g., the lumen of the delivery shaft) sothat the cut implant can be delivered to the eye through the conduitwithout the cut implant needing to be transferred to a separate deliverydevice. In some implementations, the cutting motion can be from abovethe patch of material such that the sharp edges of the blades cut thepatch of material from an upper surface of the patch. As the cutterslides through the patch of material forming the implant it can thenurge the cut implant down into the lumen of the delivery shaft along anaxis orthogonal to the longitudinal axis A of the handle. In otherimplementations, the cutting motion can be along the longitudinal axis Aof the handle sliding through the patch of material from a proximal endtowards a distal end of the handle 305. The motion of the cutting canresult in a cut implant already properly positioned and/or aligned withthe delivery conduit of the delivery shaft. The cutting member can bemovable relative to the handle as well as to a recess holding the patchof material into a cutting configuration. As the cutting member movestowards the cutting configuration it can cut the patch of material beingheld fixed within the recess forming the implant and the implant, oncecut, can be axially aligned with the conduit for delivery.

The method of preparing an implant for implantation into an implant andfor inserting the implant into the eye of patient can include insertinga patch of a material into a proximal portion of an instrument. Theinstrument can include the cutting member and a distal portion sized forinsertion into the eye. Cutting the patch with the cutting member canform the implant. The implant, which can have a longitudinal axis, canalign with a longitudinal axis of the lumen of the cutting member thatcut the implant as the cutting member finishes cutting the patch ofmaterial to form the implant.

The implant can then be advanced from the proximal portion of theinstrument into a deployment position in a lumen of an elongate tubularmember of the distal portion of the instrument. The distal portion ofthe instrument is insertable into the anterior chamber of the eye sothat it may be positioned adjacent eye tissue within which the implantis deployed from the instrument into the eye tissue. For example, thedistal portion of the instrument can be inserted ab interno into theanterior chamber through a corneal incision, while the proximal portionof the instrument remains outside the eye. It should be appreciated thatthe distal portion of the instrument can be useful for other deliverypathways (e.g., trans-scleral delivery). Deploying the implant into theeye tissue can include the implant residing at least in part between aciliary body and a sclera of the eye. The implant can reside between theciliary body and the sclera within a cyclodialysis cleft.

Inserting the patch of the material includes inserting the patch into arecess, such as in the proximal portion of the instrument. Theinstrument can include a cover that is closed over the recess containingthe patch. The cover is adapted to engage at least some portion of thepatch of material before the cutting of the patch occurs. The cover canprevent movement of the patch during the cutting of the patch with thecutting member of the instrument. The cover (or some other element) canadditional impose tensioning on at least a portion of the patch beforecutting occurs. Tensioning can involve activating an actuator tensionthe portion of the patch although tensioning need not involve a separateactuation and can be a result of closing the cover itself. Closing thecover over the recess can include engaging a portion of the cover with afirst portion of the patch to compress the first portion of the patchand to tension a second portion of the patch.

The structure desirably trephines the tissue in a manner such that thetissue can be slid, pushed, and/or pulled along the conduit toward animplanted location of the eye. In other implementations, the stent isheld fixed in place and the conduit withdrawn from the stent leaving thestent implanted within the eye. The conduit can be incorporated into orcoupled to a delivery device that implants and deploys the stent intothe eye. The trephination device can be made of any of a variety ofmaterials, such as a hard material including a plastic and/or a metal.

The trephination device 205 shown in FIGS. 2A-2B can have an internallumen or enclosure 210 sized and shaped to form the elongated contour ofthe stent 105 when tissue is positioned within the enclosure 210. Theenclosure 210 has a dimension that approximates within microns the sizeof the stent 105 to be formed. The trephination device 205 is configuredto stabilize tissue during the trephination process. In this regard, thetrephination device 205 can fix the tissue in place and prevent movementof the tissue relative to the trephination device 205 as the tissue istrephined. In an implementation, the trephination device 205 can haveone or more wings 215 configured to articulate between an open (FIG. 2A)and closed (FIG. 2B) configuration. A patch of material can be placedwithin the enclosure 210 when the trephination device 205 is in the openconfiguration. One or more blades 220 may be positioned on an innersurface of the wings 215 such that when the wings 215 are articulated tothe closed configuration and the patch of material is in place withinthe enclosure 210, the patch is cut into a stent having a desireddimension.

The enclosure 210 of the trephination device 205 can transition toand/or contain a corresponding lumen of a delivery device 110 that isconfigured to advance or otherwise inject the stent 105 into the eye. Inan embodiment, the trephination device 205 trephines or cuts the tissuealong a path that is aligned with or coaxial with a delivery pathway ofthe stent into the implanted location. For example, the stent cut fromthe patch of material held within the enclosure 210 can be urgeddistally through a lumen extending through a forward-end 222 of thetrephination device 205 into a delivery device shaft. As such, the stentcan be trephined first using a stand-alone trephination device. Thetrephination device holding the trephined stent can then be loaded intoa delivery device, which is designed to accept the trephination device.This allows for loading the stent and deploying the stent without havingto remove the stent from the trephination device in order to load itinto the delivery device.

Trephination of stent material will be described in more detail below.

With reference again to FIG. 1, a delivery device 110 is configured tobe removably coupled to the stent 105 and used to deliver the stent 105into the implanted location via an ab interno delivery pathway. Thedelivery device 110 is schematically represented in FIG. 1. Whencoupled, the delivery device 110 can be inserted into the eye and usedto implant the stent 105 in the implanted location via an ab internodelivery pathway.

The delivery devices described herein can prepare an implant and performab interno insertion of the implant into the eye. FIG. 3 shows aperspective view of an example implementation of a delivery device 110having integrated trephination. FIG. 4 shows a cross-sectional view ofthe delivery device 110 of FIG. 3. The delivery device 110 can include aproximal handle 305 that is sized and shaped to be grasped by a singlehand of a user. One or more actuators 315 can be positioned on a regionof the handle 305. The actuator 315 can also be manipulated by thesingle hand of the user such as with a thumb or finger. The actuator 315can be one or more of a knob, button, slider, or other interfaceconfigured to move one or more components of the delivery device 110 aswill be described in more detail below.

An elongated shaft 310 (also referred to herein as an applicator ordelivery body) extends in a distal direction outward from the handle305. At least a portion of the shaft 310 contains or is coupled to thestent 105 for direct stent implantation. At least a portion of the shaft310 extends along a longitudinal axis A. The shaft 310 can be angled,curved, or flexible at a distal end region such that it can form adistal curve or a bend. In some implementations, the shaft 310 caninclude a flexible portion and a rigid portion such that depending onrelative position of the portions results in a change in shape of theshaft. The shaft 310 can be curved along at least its length and/or canbe flexible.

The shaft 310 of the delivery device 110 has a size and shape isconfigured for ab interno delivery through a clear corneal incision topermit passage of the stent 105 out the distal end of the shaft 310 andleft within the eye. In at least some methods, the distal end of theshaft 310 is sized to extend through an incision that is about 1 mm inlength. In another implementation, the distal end of the shaft 310 issized to extend through an incision that is no greater than about 2.5 mmin length. In another implementation, the distal end of the shaft 310 issized to extend through an incision that is between 1.5 mm to 2.85 mm inlength. In some implementations, the maximum outer diameter of the shaft310 is no greater than 1.3 mm. The distal-most tip 316 of the shaft 310can be blunt or sharp. A blunt distal-most tip 316 of the shaft 310allows for dissecting between tissues of the eye without penetrating orcutting the tissues for positioning the stent 105. For example, thedistal-most tip 316 of the shaft 310 can be configured to bluntlydissect between the ciliary body CB and the sclera S (e.g., thesupraciliary space) while the stent 105 remains fully encased within theshaft 310 during the blunt dissection. In an alternative implementation,the distal-most tip 316 of the shaft 310 has a sharp cuttingconfiguration for dissecting application and implantation through thescleral wall into the subconjunctival space. In yet another embodiment,the distal-most tip 316 can have a cutting configuration for dissectingand implantation into the Schlemm's canal or trans-sclerally.

The stents described herein are formed as solid strips of materialwithout any lumen. Thus, the stents are not deliverable over a guidewireas many conventional glaucoma shunts are. Additionally, the stents areformed of relatively soft tissue that is more fragile as typical shuntsformed of more rigid polymeric or metal material. More rigid shunts canbe implanted such that a distal end of the shunt is used to create ablunt dissection at the interface of the tissues through which the shuntis being inserted. The stents described herein are preferably deployedusing a retractable sleeved type of injector that once in properanatomic position can be retracted leaving the stent more gentlyexternalized and position. Additionally, the stents described herein canbe deployed in the eye by urging the stent distally through at least aportion of the shaft 310. The stents can have a dimension thatsubstantially fills an inner lumen of the shaft 310 (or the inner lumenof at least a portion of the shaft 310 through which it is delivered)such that the stent may be urged distally through that portion withoutwrinkling or being damaged. The tolerance between the outer dimensionsof the stent 105 and the inner dimension of the conduit can be up toabout 200%. The conduit can also be coated with a lubricious material(e.g., Teflon) to improve advancement of the stent 105 through theconduit during deployment.

The shaft 310 can define an internal, hollowed shape for containing thestent 105. In some implementations, the shaft 310 can be formed of anouter tube 318 (also referred to herein as a tubular outer sheath) andan inner pusher 320 (also referred to herein as an elongate member)positioned within the lumen of the outer tube 318 (see FIG. 4 and alsoFIGS. 7, 11C-11E). Movement of the outer tube 318 and/or the pusher 320can act to deploy the stent 105 within the eye. The outer tube 318 andpusher 320 of the shaft 310 can be operatively coupled to the one ormore actuators 315 in order to deliver a stent 105 to the eye. The outertube 318 can be fixed relative to the handle 305 and the pusher 320moveable relative to the handle 305. The outer tube 318 can be movablerelative to the handle 305 and the pusher 320 fixed relative to thehandle 305. Alternatively, both the outer tube 318 and the pusher 320can be movable relative to the handle 305. Motion of the outer tube 318and/or the pusher 320 can be generated using the same actuator 315 ordifferent actuators 315 on the handle 305 that can be actuated by a usermoving the actuator 315 relative to the handle 305. The type of movementof the actuator 315 relative to the handle 305 can vary, includingsliding or rotatable movement. The implementation shown in FIGS. 3 and 4can include a shaft 310 having an outer tube 318 and a pusher 320. Theouter tube 318 can be coupled to a slider and the pusher 320 can becoupled to a knob 311 at a proximal region of the handle 305.

Once the desired position in the tissues is reached with the distal endof the shaft 310, the stent 105 is left in position in the eye and theshaft 310 withdrawn. In an implementation, the outer tube 318 of theshaft 310 is retracted, for example, using the actuator 315 on thehandle while the pusher 320 remains stationary relative to the handle305. The pusher 320 therefore can act as a stopper thereby preventingthe stent 105 from following the outer tube 318 as it is retracted. Theresult is that the stent 105 is unsheathed from the shaft 310 and leftwithin the tissues.

The delivery device 110 can further include a cutting member 312 (seeFIG. 4), such as a blade or cutter tube, that can move relative to thehandle 305 to cut tissue thereby forming the stent 105. As mentionedabove, the stent 105 can be formed from a patch of material. The patchof material may be loaded within a region of the delivery device 110 andcut into a smaller stent shape at the time of delivery. The cuttingmember 312 can be actuated by a user to create the stent from the patchof material.

In an example embodiment, the cutting member 312 is attached to a cover314 that is movable relative to the handle 305 (see FIGS. 3-4). Thecover 314 can be coupled to a distal end region of the handle 305 by ahinge 317 such that the cover 314 can rotate around a pivot axis P ofthe hinge 317 relative to the handle 305. The cover 314 can be lifted topivot into an open configuration (see FIG. 3) revealing a recess 321within which a patch of material 101 can be positioned and held fixedrelative to the handle. When the cover 314 is rotated back around thepivot axis P into the closed configuration, the patch of material 101positioned within the recess 321 is compressed and/or tensioned betweenthe cover 314 and the handle 305. The compression and/or tension of thepatch of material 101 can help to assure a clean and complete cut of thematerial. In some implementations, the patch of material 101 is placedunder tension such as by outward stretching by the cover 314 prior tocutting with the cutting member 312. The patch of material 101 may bestretched outward from the cutting locations as shown in FIGS. 15A-15C.

The recess 321 can be within a proximal portion of the instrument suchas with a portion of the handle 305. The recess 321 for holding thepatch of material 101 may also be a recess within a cartridge removablycoupled to a portion of the instrument, such as within a region of thehandle 305 or coupled to a distal portion of the instrument.

It should be appreciated that tensioning the patch can includeactivating a separate actuator to tension the patch. Tensioning can alsobe achieved during the stabilization and compression step without aseparate actuation. For example, closing the cover 314 alone may resultin both compression and tensioning of the patch of material without aseparate actuator to provide the tension on the patch of material aftercompression.

The cover 314 can open along any of a number or orientations relative tothe handle. For example, the pivot axis P of the hinge 317 can besubstantially orthogonal to the longitudinal axis of the handle A. Inthis implementation, the hinge 317 can be positioned on a distal end ofthe handle 305 between the shaft and the cover 314 such that the cover314 hinges open by rotating upward and toward the shaft (see, e.g.,FIGS. 3 and 4). Alternatively, the hinge 317 can be positioned such thatthe cover 314 hinges open by rotating upward and toward the proximal endregion of the handle 305 (see, e.g., FIGS. 5 and 6A-6B) In still otherimplementations, the hinge 317 can be positioned on a side of the handle305 such that the pivot axis P and the longitudinal axis A aresubstantially parallel with one another. In this implementation, thecover 314 can swing outward away from the longitudinal axis A of thehandle 305 (see, e.g., FIGS. 15A-15C). Any of a variety ofconfigurations are considered herein.

The cutting member 312 can extend from a lower surface of the cover 314to cut the patch of material 101 (e.g. bio-tissue) in a guillotine typemanner. FIG. 4 shows the cover 314 in an open configuration raised awayfrom the recess 321 within which a patch of material 101 is positioned.The cutting member 312 can extend from a lower surface of the cover 314such that its cutting surface penetrates the patch of material 101. Insome implementations, the cutting member 312 is coupled to a movableactuator or push-button 313 that can be actuated to move the cuttingmember 312 from a sheathed configuration towards a cuttingconfiguration. Once the cover 314 is in a closed configurationcompressing and/or stretching the patch of material 101 between thelower surface of the cover 314 and the housing 305, the movable actuator313 may be urged downward relative to the cover 314 placing the cuttingmember 312 into a cutting configuration. The cutting member 312 canextend below the lower surface of the cover 314 and slice through thepatch of material 101 held within the recess 321. One of more returnsprings 323 can urge the actuator 313 back upward such that the cuttingmember 312 is once again in the sheathed configuration. The cuttingmember 312 cuts the patch of material into an implant as the cuttingmember moves towards the cutting configuration. The implant, once cut,is also axially aligned with the lumen of the shaft.

It should be appreciated that other types of cutting mechanisms can beused. For example, lowering of the cover 314 may also cut the patch ofmaterial 101 held within the recess 321 in a rotating type cuttingmotion. In this implementation, the cutting member 312 extends below theplane of the lower surface of the cover 314 such that the blade edgesare available to cut the patch of material 101 upon rotating the cover314 into the closed configuration. Alternatively, the cutting motion maybe an axial cutting motion with a slidable cutting tube such thattrephination occurs along the implantation conduit as opposed to acutting motion orthogonal to the plane of the patch of material 101.

As mentioned above, as the cutting member moves towards the cuttingconfiguration it cuts the patch of material into an implant. Theimplant, once cut, is also axially aligned with the lumen of the shaftfor deployment into the eye. Thus, motion of the cutting member 312simultaneously cuts the stent and places the cut stent into a positionrelative to the shaft 310 such that the stent can be delivered throughthe shaft 310. The cutting member 312 in order to cut the patch ofmaterial 101 into a rectangular stent shape can include a pair of bladesseparated by a spacer. The spacer between the pair of blades can engagewith the cut stent 105 following cutting by the blades to urge the stent105 downward through a slot in the outer tube 318. The pusher 320 can bein a fully retracted configuration via the knob 311 such that the lumenof the outer tube 318 is free to accept the cut stent 105 through theslot. It should be appreciated that the stent 105 may be urged downwardinto a position relative to the delivery device that aligns the stent105 with the path of implantation while not specifically loaded into thelumen of the outer tube 318. For example, loading into the lumen of theouter tube 318 can occur upon an additional step such as advancement ofthe stent 105 towards the lumen of the outer tube 318 following cutting.A variety of sheath loading configurations is considered herein,including top-loading as described above, front-loading, rear-loading,and side-loading, which will be described in more detail below.Regardless of the configuration, the trephination of the patch ofmaterial 101 can place the stent 105 in a position (i.e. axially alignedwith the lumen of the shaft) that allows for it to be deployed into theeye without necessitating manual tissue transfer of the tiny piece ofcut material.

FIG. 5 shows another implementation of a delivery device 110. Thisimplementation has a detachable trephination cartridge 205 close to thetip of the delivery device 110. This implementation reduces or minimizesa travel distance of the stent 105 once the stent has been formed withinthe lumen of the shaft 310.

As with the previous implementation shown in FIGS. 3 and 4, the deliverydevice 110 can include a proximal handle 305 having one or moreactuators 315 and a shaft 310 extending from a distal end region of thehandle 305. The actuators 315 can include a first and second sliderconfigured to move the outer sheath and the pusher of the shaft 310,respectively. It should be appreciated that the device 110 need notincorporate multiple actuators 315 to achieve motion of multiplecomponents. For example, the device 110 can include a single actuator315 configured to cut and deploy the stent 105, for example by causingmotion of both the outer sheath and pusher based on, for example, thedegree of actuation of the slider.

The trephination cartridge 205 can include a base 324 and a cover 314movably attached to the base 324. The cover 314 and base 324 can becoupled together by a hinge 317 such that the cover 314 rotates around apivot axis of the hinge 317. As with the previous implementation, thecover 314 can be lifted to pivot into an open configuration revealing arecess 321 of the base 324 within which a patch of material can bepositioned and held fixed. When the cover 314 is rotated back aroundinto the closed configuration, the patch is compressed and/or tensionedbetween the cover 314 and the base 324. The cover 314 and base 324 neednot be hinged relative to one another. For example, the cover 314 andbase 324 can simply uncouple revealing the upper surface of the base 324such that the shaft 310 and patch of material 101 can be positionedappropriately relative to the trephination cartridge 205. The cover 314can be configured to additionally apply an amount of tension on thepatch of material 101, such as stretching in an outward direction fromthe center of the patch of material 101 to improve cutting.

FIG. 6A shows the delivery device 110 having a trephination cartridge205 coupled to a distal end region of the handle 305 in a closedconfiguration in which an upper surface of the base 324 and a lowersurface of the cover 314 of the trephination cartridge 205 are opposedagainst one another. FIG. 6B is a cross-sectional view of the device 110in FIG. 6A illustrating the shaft 310 extending through the handle 305.

The trephination cartridge 205 can be provided pre-loaded with a patchof material positioned within the recess. For example, the patch ofmaterial can be compressed and/or tensioned within the base 324 andcover 314. The cutting member 312 can then be actuated to punch out astent 105 from the patch of material, for example, by pressing down onthe push-button 313 to urge the cutting member 312 through the patch ofmaterial held within the trephination cartridge 205. The delivery device110 and trephination cartridge 205 can then be engaged to each other.For example, the shaft 310 can insert through a proximal port on thetrephination cartridge 205 thereby front-loading the cut stent 105 intothe outer tube 318 for delivery into an eye. The cut stent 105 can beheld fixed within the trephination cartridge 205. In still furtherimplementations, the stent can be loaded into a cutout opening in theshaft from above, or front-loaded, or from a rear of the shaft.

It should be appreciated that the patch of material need not be cut intothe stent by a user at the time of implantation into a subject. Thepatch of material may be cut into the stent well before the time ofimplantation, such as at the tissue bank or tissue engineering lab. Thestent can be provided as a pre-cut, pre-loaded stent within a cartridgeconfigured to couple with the delivery device. For example, thetrephination cartridge 205 can be provided to a user pre-loaded with apre-cut stent 105 from the patch of biologically-derived material. Thecartridge 205 holding the stent 105 can be coupled with the deliverydevice at the time of implantation. Once coupled together, a user canload the stent 105 into the shaft 310 of the delivery device asdescribed elsewhere herein. In still further implementations, the stent105 can be provided to a user pre-loaded within the lumen of shaft 310.The patch of material can be provided in the cartridge or in the lumenof the shaft 310 emerged in an appropriate tissue preservative media asis known in the art.

In an implementation, the user can manually load a patch of material 101through opposing cut-out windows 326 extending through the outer tube318 of the shaft 310 of the delivery device 110 (see FIG. 7). Thecut-out windows 326 in the outer tube 318 can extend through opposingsidewalls such that the patch of material 101 can be inserted through afirst cut-out window 326, traverse the lumen 328 of the outer tube 318,and insert through the second cut-out window 326 on the opposite side ofthe lumen 328. The dimensions of the cut-out 326 are sufficient to loadthe patch of material 101 through the cut-out 326 as shown in FIG. 7.The patch of material 101 can have a dimension that is wider than anouter diameter of the outer tube 318 such that each side of the patch101 extends beyond the sidewalls of the outer tube 318. The cut-outwindows 326 in the outer tube 318 can each have a length along thelongitudinal axis A of the shaft 310 that is at least as long as alength of the patch of material 101. The cut-out windows 326 in theouter tube 318 can have a depth that is at least as thick as thethickness of the patch of material 101. FIG. 8A is a top-down schematicview of the cut-out windows 326 of the shaft 310. FIG. 8B is across-sectional view of FIG. 8A taken along line B-B. The cut-outwindows 326, which can be created by removing a side wall on either sideof the outer tube 318), form narrow webs 330 on an upper and lowersurface of the tube 318.

FIGS. 9A-9B show another implementation of a trephination cartridge 205having a cover 314 and a base 324. FIG. 9A shows the base 324 with thetop cover 314 installed. FIG. 9B is a cross-sectional view of thecartridge 205 showing the tissue patch 101 sandwiched between the base324 and the cover 314. FIG. 9C shows the base 324 of the trephinationcartridge 205 loaded with a patch of material 101 loaded within thecut-out windows 326 of the tube 318 and positioned within the recess 321of the base 324. The recess 321 can be positioned between a proximalslot 332 and a distal slot 334. The proximal slot 332 is sized toreceive at least a portion of the outer tube 318 located proximal to thecut-out windows 326 and the distal slot 334 is sized to receive theportion of the outer tube 318 located distal to the cut-out windows 326.The recess 321 can have any of a variety shapes, but is generally sizedto receive the patch of material 101 loaded within the cut-out windows326 of the outer tube 318. Thus, when the shaft 310 of the deliverydevice 110 is inserted into the trephination cartridge 205, the shaft310 is received within the proximal and distal slots 332, 334 and thetissue patch 101 sits within the recess 321.

Still with respect to FIGS. 9A-9C, the cover 314 can have an uppersurface forming an external surface of the cartridge 205. The cover 314can also include a lower surface configured to engage with an uppersurface the cartridge base 324. The upper surface can include a recess336 within which is an entrance to a bore 338 extending from the uppersurface through a full thickness of the cover 314 to the lower surface.The upper surface of the cartridge base 324 includes an entrance to abore 340 extending through at least a thickness of the base 324. Thebore 340 of the base 324 can, but need not extend through the fullthickness of the base 324. When the cover 314 abuts the base 324, thebores 338, 340 are aligned such that a contiguous channel is formed. Thecontiguous channel is sized and shaped to receive the cutting member312, which will be described in more detail below. The cutting member312 can translate relative to the cartridge 205 and extend from theupper surface of the cover 314 through the full thickness of the cover314 into the bore 340 of the base 324.

The lower surface of the cover 314 surrounding the bore 338 in the cover314 and the upper surface of the base 324 surrounding the bore 340 inthe base 324 can compress the patch of material 101 positionedtherebetween. The recess 321 in the base 324 can have a depth that isless than a thickness of the patch 101 positioned within the recess 321such that when the cover 314 is coupled to the base 324, the patch ofmaterial 101 is compressed between the cover 314 and base 324. Thecompression of the patch of material 101 between the base 324 and thecover 314 helps to prevent movement of the patch of material 101 duringcutting with the cutting member 312. Tension can also be applied to thepatch of material 101 prior to cutting. In some implementations, thecover 314 is hinged relative to the base 324 (see FIG. 5). The cover 314and base 324 can be reversibly fixed to one another such that uponclosing the cover 314 onto the base 324, the cover 314 latches orotherwise reversibly couples to the base 324 to prevent inadvertentopening of the cover 314 relative to the base 324.

FIG. 10A illustrates the trephination cartridge 205 with the base 324and cover 314 in a closed configuration. FIG. 10B is a cross-sectionalview of the trephination cartridge 205 in a closed configuration withthe patch of material 101 sandwiched between the cover 314 and base 324and the cutting member 312 inserted into the bore 338 of the cover 314.FIG. 10C is a cross-sectional view of the trephination cartridge 205with the cutting member 312 advanced fully through the cover 314 andinto the bore 340 of the base 324.

The cutting member 312 can include a pair of blades 344 and an enlargedgrip feature or handle 343. The handle 343 is positioned on an upper endof the blade housing 342 whereas the pair of blades 344 project from alower end of the blade housing 342. The handle 343 can be shaped andsized for a user to comfortably grip the cutting member 312. FIGS.10A-10C illustrates the handle 343 as having a disc shape configured tobe received within the correspondingly shaped recess 336 in the uppersurface of the cover 314. Any of a variety of shapes are consideredherein.

The blade housing 342 can include a central channel 346 within which anupper portion of the blades 344 are received. The lower cutting surfacesof the blades 344 extend below the blade housing 342. The pair of blades344 can be separated from one another by a spacer 345 defining a gapbetween the blades 344. The gap size is selected based on the desiredwidth of the stent 105 to be achieved upon cutting the patch of tissue101 with the blades 344.

The cutting member 312 can be received within the recess 336 in thecover 314 such that the blades 344 extending from a lower end of thecutting member 312 insert first through the bore 338 in the cover 314followed by the blade housing 342 (see FIG. 10A). Thus, the bore 338 ofthe cover 314 can be sized and shaped to receive not just the blades344, but also at least a portion of the blade housing 342. The handle343 can be sized and shaped to be received within the recess 336 in thecover upon full insertion of the cutting member 312 within the cartridge205.

The tissue patch held within the cut-out region of the shaft is cut intwo locations creating a narrow strip of material (i.e. the stent 105)from the patch of material 101. As the cutting member 312 is urgedfurther through the bore 338 in the cover 314, the blades 344 are urgedtowards the patch of material 101 compressed between the cover 314 andthe base 324 (see FIG. 10B). As the cutter is urged further through bore338 of the cover 314 and enters bore 340 of the base 324, the blades 344slice through the patch of tissue 101 positioned within the recess 321(see FIG. 10C). The blades 344 make two cuts in the patch of material101 as it extends down through bore 340 of the base 324 completelycutting through the patch 101 forming a stent 105. Motion of the cuttertowards the cutting configuration cuts the patch of material into thestent as the cutting member moved towards the cutting configuration andthe stent, once cut, is axially aligned with the lumen 328 of the outertube 318. The stent 105 that is formed is thereby already loadedrelative to or within the lumen 328 of the outer tube 318 such that noloading step is necessary.

The blades 344 have inserted through the contiguous channel formed bythe bores 338, 340 of the cover 314 and the base 324. The housing 342can seat within the bore 338 and/or the handle 343 can seat within therecess 336 of the cover 314 thereby preventing any further downwardmotion of the blades 344. The stent 105 that is formed is held snuglywithin the lumen 328 of the outer tube 318. As mentioned above, theouter tube 318 of the delivery device shaft 310 can include a pair ofcut-out windows 326 on opposing sidewalls creating narrow webs 330 on anupper and lower surface of the tube 318. As best shown in FIGS. 11A-11E,each of the blades 344 is received within a respective cut-out window326 of the tube 318 when the cutting member 312 is inserted within thecartridge 205 so that the blades 344 extend into the bore 340 in thebase 324. The gap between the pair of blades 344 is sized to accommodateand receive the webs 330 as the blades 344 slide past the shaft 318positioned within the cartridge 205. The stent 105 once cut is containedwithin the lumen 328 of the outer tube 318 at the location of thecut-out windows 326 with one of the pair of blades 344 enclosing thestent 105 on a first side and a second of the pair of blades 344enclosing the stent 105 on a second opposite side. The enclosure createsthe path for the stent 105 to be deployed from lumen 328 out the distalend of the shaft 310, which will be described in more detail below.

Still with respect to FIGS. 11A-11E, the blades 344 can include singlebevel edges that are angled to propagate the cut, similar to scissors.It is preferred that the blades 344 not chop tissue. The blades 344 arepositioned relative to the cartridge 205 such that a complete cutthrough the patch 101 occurs upon full travel of the cutting member 312through the cartridge 205.

Upon complete translation of the cutting member 312 into the cover 314(i.e., placement of the cutting member 312 into the cuttingconfiguration), the blade housing 342 is constrained within the bore 338in the cover 314. Thus, a length of the blade housing 342 is no longerthan and preferably slightly shorter than a depth of the bore 338 in thecover 314. In some implementations and as best shown in FIG. 10B, thedistal exit from the bore 338 at the lower surface of the cover 314 canhave a smaller dimension than the entrance to the bore 338. Where theentrance to the bore 338 is sized to receive the blade housing 342, theexit from the bore 338 may be sized to receive only the blades 344 andnot the blade housing 342. This arrangement can prevent over-insertionof the cutting member 312 relative to the cartridge 205 in that thelower end region of the bore 338 acts as a stop for the blade housing342.

The cutting member 312 can additionally include a safety sheath (notshown) configured to enclose the dual blades 344 extending from a lowerend of the blade housing 342. The safety sheath can prevent inadvertentdamage to the blades 344 or the user when the cutting member 312 is notengaged with the cartridge 205. For example, the safety sheath canenclose the blades 344 on all but a lower end of the cutting member 312.The cover 314 and base 324 of the cartridge 205 can include additionalchannels aligned, sized and shaped to receive the safety sheathsurrounding the blades 344 as the cutting member 312 is inserted intothe cartridge 205.

FIG. 11E shows a cross-sectional view of the cut-out windows 326 of theouter tube 318 with the blades 344 positioned on either side of theupper and lower webs 330. As mentioned, the shaft 310 of the deliverydevice 110 can include a pusher 320 positioned within the lumen 328 ofthe outer tube 318. At least a portion of the pusher 320 can have across-sectional shape configured to slide past the blades 344 positionedwithin the cut-out windows 326 of the tube 318. The cross-sectionalshape of at least a portion of the pusher 320 can incorporate flat sidesconfigured to align with the cut-out windows 326 upon extension of thepusher 320 relative to the outer tube 318 during deployment of the stent105 from the lumen 328. The flat sides of the pusher 320 (as opposed toconvex sides) can define a width that is sized to slide between the twoblades 344 positioned within the cut-out windows 326. Like the stent, atleast a portion of the pusher 320 can be sized to completely fill atleast a portion of the lumen 328 of the outer tube 318. The outer tube318 can be a hypotube that is no greater than about 18 G (0.050″ OD,0.033″ ID), 20 G (0.036″ OD, 0.023″ ID), 21 G (0.032″ OD, 0.020″ ID), 22G (0.028″ OD, 0.016″ ID), 23 G (0.025″ OD, 0.013″ ID), 25 G (0.020″ OD,0.010″ ID), 27 G (0.016″ OD, 0.008″ ID), 30 G (0.012″ OD, 0.006″ ID), or32 G (0.009″ OD, 0.004″ ID). In some implementations, the outer tube 318is a hypotube having an inner diameter that is less than about 0.036″down to about 0.009″. The dimensions of the outer tube 318 can beselected based on the dimensions desired for the stent to be implantedas discussed in more detail above.

While the shaft 310 of the delivery device 110 is installed in thecartridge 205 and the blades 344 are still positioned in the cuttingconfiguration, the pusher 320 can be pushed distally away from thehandle 305 of the delivery device 110 to position the stent 105 cut fromthe patch of material 101 into a primed position within the lumen 328.In some implementations, the pusher 320 can be advanced distallyrelative to the handle 305, for example, using an actuator 315 on thehandle 305. The presence of the blades 344 on either side of the cut-outwindows 326 and the webs 330 on the upper and lower sides prevents thestent 105 from buckling within the lumen 328 during this priming step.The conduit within which the stent 105 is held is size-matched to theouter dimension of the stent being implanted thereby preventing bucklingand wrinkling as the stent 105 is urged into the primed position.

Once the stent 105 is urged into the distal tip region of the outer tube318, the blades 344 can be retracted from the base 324. In someimplementations, the cutting member 312 can be removed from thecartridge 205 and the cover 314 opened relative to the base 324 so thatthe shaft 310 of the delivery device 110 can be removed from thecartridge 205. In other implementations, the cutting member 312 can bewithdrawn from the base 324, but still engaged with the cartridge 205for the shaft 310 of the delivery device 110 to be removed from thecartridge 205. The shaft 310 can be withdrawn from the cartridge 205with or without the cover 314 being in an open configuration. Once thedelivery device 110 and the cartridge 205 are disengaged with oneanother, the delivery device 110 is ready to be used to insert the stent105 into the eye, which will be described in more detail below.

As mentioned above, movement of the components of the delivery device110 can be achieved using one or more actuators 315 of the handle 305.FIG. 6B is a cross-sectional view of an implementation of the deliverydevice 110 having its distal shaft 310 engaged with a trephinationcartridge 205. The shaft 310 can include a pusher 320 and an outer tube318. The pusher 320 can be coupled to a first actuator 315 and the outertube 318 can be coupled to a second actuator 315. Each of the first andsecond actuators 315 can be sliders configured to advance and retracttheir respective components. The first actuator 315 can be withdrawnproximally such that the pusher 320 is in its most proximal positionrelative to the outer tube 318 during cutting of the patch of material101 compressed and/or tensioned within the cartridge 205. Once the patchof material 101 is cut, the user can advance the first actuator 315 tourge the pusher 320 distally to prime the stent 105 within the lumen 328of the outer tube 318 towards the distal end of the shaft 310. After thecut stent 105 is primed into its distal position within the lumen 328,the cartridge 205 can be disengaged from the shaft 310. The outer tube318 of the delivery device 110 can be used to dissect tissue of the eyeuntil a target location is accessed. Once the delivery device is inposition to deploy the stent 105 in the eye, the first actuator 315coupled to the pusher 320 can be maintained in this distal position andthe second actuator 315 withdrawn to retract the outer tube 318. Thisrelative movement of the outer tube 318 to the pusher 320 deploys thestent 105 from the lumen 328 in the anatomy (as shown in FIG. 12B). Itshould be appreciated that additional distal movement of the pusher 320can be used to aid in deployment of the stent 105 from the lumen 328. Itshould also be appreciated that pusher 320 advancement and outer tube318 retraction can be controlled by dual actuators 315 as describedabove or by a single actuator 315 capable of both pusher and outersheath movement depending on degree of actuation. Additionally, theshaft 310 of the delivery device 110 can be used to inject viscoelasticduring the procedure using the pusher 320 as a plunger.

FIGS. 13A-13B and FIGS. 18A-18B show interrelated implementations of adelivery device 1110 having integrated trephination forming a system forpreparing an implant and performing ab interno insertion of the implantinto the eye. As described elsewhere herein, the delivery device 1110can be inserted into the eye and used to implant the stent 105 in theimplanted location via an ab interno delivery pathway. The deliverydevice 1110 can include a proximal portion such as a proximal handle1305 that is sized and shaped to be grasped by the user and remainsoutside of a patient's eye. The delivery device 1110 can also include adistal portion. The distal portion can include an elongate deliveryshaft 1310 extending distally from the proximal handle 1305. Theelongate delivery shaft 1310 includes an outer tube 1318 having a lumen1328 (see FIG. 14A). An axially movable cutter tube 1312 can bepositioned within the handle 1305. A pusher 1320 is shown positionedwithin the lumen 1378 of the cutter tube 1312. The pusher 1320 isconfigured to be advanced distally through the lumen 1328 of the outertube 1318. It should be appreciated that where the delivery devices aredescribed herein as suitable for performing ab interno insertion of animplant that other approaches for implantation are considered as well.For example, the delivery devices may be used to perform a trans-scleralapproach for delivery of the implant.

Still with respect to FIG. 14A, the delivery device 1110 can include anaccess door 1314 coupled to a region of the handle 1305, such as by ahinge 1317, so that the door 1314 can be rotated around the pivot axisof the hinge 1317 relative to the handle 1305. When the access door 1314is in an open configuration, a recess 1321 is revealed. The patch ofmaterial 101 may be loaded within the recess 1321 for cutting into astent 105 prior to delivery. The pusher 1320 positioned within the lumen1378 of the cutter tube 1312 is retracted proximally relative to therecess 1321 such that the patch of material 101 may be positioned withinthe recess 1321. FIG. 14B shows the access door 1314 rotated to a closedconfiguration capturing the patch of material 101 within the recess1321. In some implementations, the access door 1314 can be formed of atransparent or translucent material such that the patch of material 101positioned within the recess 1321 may be visualized by a user followingloading (see also FIG. 18A). The access door 1314 can also include oneor more latches 1322 (see FIG. 19A) to ensure once the door 1314 isclosed it remains closed until a user desires to open the door 1314again. In some implementations, the latch of the access door 1314 caninclude interference fit features or magnets, or other element.

The recess can be within a portion of the instrument such as within thehandle as described above. The recess may also be within a cartridgeremovably coupled to the instrument. The cartridge can be coupled to adistal portion of the instrument as shown herein and removed prior todeployment in the eye. The cartridge can also be coupled to a proximalportion of the instrument and may or may not be removed prior todeployment.

When the door 1314 is rotated around the pivot axis P from an openconfiguration into a closed configuration, the patch of material 101positioned within the recess 1321 can be captured, compressed, and/ortensioned. The door 1314 can be adapted to engage at least some portionof the patch of material before the patch is cut. The door 1314 canprevent movement of the patch during the cutting with the cutter.

In some implementations, at least a portion of the recess 1321 can havea depth, for example, the portion aligned with a centerline of theimplantation conduit, that is less than the thickness of the patch ofmaterial 101 held within the recess 1321. Upon closing the door 1314,the patch of material 101 is compressed slightly.

At least a portion of the patch of material 101 can be placed undertension prior to cutting. The cutting achieved by the cutter tube 1312is improved when the patch of material 101 is placed under slighttension before cutting. The tensioning of the portion of the patch caninclude compressing a first portion and a second portion of the patchand tensioning a central portion of the patch, the central portionlocated between the first and second portions. The central portion ofthe patch becomes the implant upon cutting the patch with the cuttertube 1312.

Tensioning the portion of the patch can include activating an actuatorto tension the portion of the patch. Activating the actuator can includerotate an actuator to tension the portion of the patch. For example, thecover can include an actuator and actuation of the actuator can tensionat least a portion of the patch. However, tensioning need not be aseparate actuation. As discussed elsewhere herein, closing the accessdoor 1314 can provide both fixation and an amount of tension on thepatch. FIGS. 15A-15C are cross-sectional schematic views of the handle1305 showing the access door 1314 and the patch of material 101positioned within the recess 1321. The door 1314 can include a featureconfigured to apply a small amount of tension or stretching force ontothe patch of material 101 to improve cutting. The door 1314 can becoupled to a stretcher 1350 having a pair of flexible stretcher legs1352. The stretcher legs 1352 extend into the recess 1312 until each ofthe feet 1354 at the end of the legs 1352 contact the patch of material101 (see FIG. 15B). One foot 1354 can contact a first portion of thepatch of material 101 on a first side of the center line and an oppositefoot 1354 can contact a second portion of the patch of material 101 on asecond, opposite side of the center line. The stretcher 1350 can beactuated from a first position in which the stretcher 1350 is elevatedrelative to the recess 1321. When the stretcher 1350 is urged downward,the stretcher legs flex and the feet 1354 are urged outward further awayfrom the center line and away from one another (see arrows in FIG. 15C).The distance between the feet 1354 is sufficient to allow for the cuttertube to slide through the recess 1321 between the feet 1354 in an axialdirection to cut the patch of material 101. The lower surface of thefeet 1354 can have surface features 1355, for example ridges, bumps, orother texture that optimizes the interface between the feet 1354 and thepatch of material 101. The surface features 1355 allow the feet 1354 tostretch the patch of material 101 outward as the feet 1355 are urgedoutward.

The stretcher 1350 can have any of a variety of configuration. Thestretcher 1350 can be a button as shown in FIGS. 13A-13B and 15A-15C.The stretcher 1350 can be a dial as shown in FIGS. 18A-18B, FIGS.19A-19B, FIGS. 20A-20C, FIG. 21, and FIG. 22. Any of a variety of otheractuators are considered that are configured to impart tension on thepatch 101. In implementations where the stretcher 1350 is a button thedoor 1314 can additionally incorporate a stretch release button 1357(see FIG. 13A) to release the tension applied, if desired.

Regardless the configuration, the stretcher 1350 can have an upper endregion 1360 and a lower end region 1362 (see FIG. 20A) The upper endregion 1360 is configured to be gripped and actuated (i.e. pushed orrotated). The lower end region 1362 of the stretcher 1350 can engagewith the access door 1314. FIG. 21 shows an implementation of thestretcher 1350 that is a dial having threads 1367 on the lower endregion 1362 of the stretcher 1350 that engage with corresponding threads1365 of a bore 1364 in an upper surface of the door 1314. Rotation ofthe stretcher 1350 relative to the bore 1364 draws the stretcher 1350further down into the bore 1364 and urges the feet 1354 further into therecess 1312.

As discussed elsewhere herein, tensioning the patch can includeactivating an actuator such as the dial to tension the patch. Tensioningcan also be achieved without a separate actuation. For example, closingthe door 1314 may achieve both fixation and tension of the patch ofmaterial without a separate actuator to provide the tension on the patchof material after compression. The door 1314, therefore, can achieve aprefixed tension on the patch of material upon closure without aseparate activation of the stretcher 1350 up or down relative to thematerial.

The recess 1321 receives the patch of material 101. The recess 1321 caninclude a projection 1371 in the shape of an inverted V can projectupward from a center line of the recess 1321 that urges the centerlineof the patch of material 101 upward toward the door 1314 while allowingthe sides of the patch of material 101 to hang downward intocorresponding channels 1370 on either side of the centerline (see FIG.19A and FIG. 21). Upon closing the door 1314, the stretcher legs 1352extend into the recess 1312 until each of the feet 1354 of the stretcherlegs 1352 contact the sides of the patch of material 101 hanging withinthe channels 1370 (see FIG. 21). One foot 1354 can contact a firstportion of the patch of material 101 in a first channel 1370 adjacentthe center line and an opposite foot 1354 can contact a second portionof the patch of material 101 in a second channel 1370 on the oppositeside of the center line. When the stretcher 1350 is drawn further intothe bore 1364, such as by turning the dial, the feet 1354 urge theseportions deeper into their respective channels 1370 thereby compressingthe centerline of the patch of material 101 against the inverted V 1371of the recess 1321 (see FIG. 21). The distance between the feet 1354 issufficient to allow the cutter tube 1312 to pass between them. Theinverted V 1371 can include a shallow central channel 1372 sized andshaped to receive the lower wall geometry of the cutter tube 1312 as thecutter tube 1312 is advanced distally to cut the patch of material 101.

The cutting member can include a cutting member lumen, a distal opening,and a pair of opposed cutting edges. The cutting can include advancingthe cutting member to cut a patch of material and capture the implantwithin the cutting member lumen. The pair of opposed cutting edges cancut the patch in two locations to separate the implant from a remainderof the patch of material. A distal portion of the cutting member can bebeveled. The longitudinal axis of the implant can remain aligned with alongitudinal axis of the lumen of the cutting member as the cuttingmember finishes cutting the patch to form the implant.

The cutter tube 1312 can be a dual beveled hypotube forming two leadingpoints 1372 (see FIGS. 23A-23D). The two leading points 1372 can bepositioned above and below the patch of material 101, respectively, asthe cutter tube 1312 is advanced into a cutting configuration and slicesthrough the patch of material 101. The lower leading point 1372 can bereceived within the shallow central channel 1372 of the inverted V 1371and the upper leading point 1372 glides over the patch of material 101.The leading points 1372 can be blunt or sharp. The cutting surfaces ofthe cutter tube 1312 include the inside edges 1374 of each bevel 1376.The inside edges 1374 are separated from one another by the lumen 1378of the cutter tube 1312 so that the cutter tube 1312 slices the patch ofmaterial 101 in two locations. Thus, the inner diameter or distancebetween inside edges 1374 of the cutter tube 1312 determines the widthof the stent 105 that is cut.

The stent 105, once cut, is contained within the lumen 1378 of thecutter tube 1312 creating an enclosure for the stent 105. The stent 105can have a dimension that substantially fills the lumen 1378 of thecutter tube 1312. The axial motion of the cutter tube 1312 in a distaldirection towards the cutting configuration positions the cutter tube1312 so that its walls bridge the recess 1321 and forms part of theimplantation conduit 1319. The lumen 1378 of the cutter tube 1312 can becoaxial (e.g., contiguous or non-contiguous) with the lumen of theelongate shaft 1310 through which the stent 105 will be delivered to theeye. For example, as shown in FIG. 17B, the cut stent 105 may beadvanced out of the cutter tube 1312 along the implantation conduit 1319towards the distal end of the delivery shaft 1310. Thus, the axialmotion of the cutter tube 1312 along an axis of the implantation conduit1319 simultaneously cuts the stent from the patch of material 101 andaxially aligns the cut stent with or relative to the delivery shaftlumen such that the stent 105 may be deployed in the eye without anytissue transfer step.

The inner elongate member or pusher 1320 is movable relative to thedelivery shaft lumen. The stent 105 can be pushed distally out from thecutter tube 1312 by the pusher 1320. As discussed above, the elongateshaft 1310 of the delivery device 1110 can include an outer tube 1318and an inner pusher 1320 positioned within the lumen of the outer tube1318. The pusher 1320 is sized and shaped to travel distally through thelumen 1378 of the cutter tube 1312 to urge the stent 105 towards thedistal end of the outer tube 1318 (see FIG. 17B). In someimplementations, the outer tube 1318 is fixed relative to the handle1305 and the inner pusher 1320 is movable relative to the outer tube1318 to deploy the stent 105 from the outer tube 1318. In otherimplementations, both the outer tube 1318 and the pusher 1320 aremovable relative to the handle 1305 and to each other. The distal end ofthe pusher 1320 can be shaped to atraumatically urge the stent 105 inthe distal direction.

In still further implementations, the elongate delivery shaft 1310 caninclude a fixed outer tube 1318 and an introducer tube 1380 positionedand movable through the lumen 1328 of the outer tube 1318 (see FIGS.18A-18B). The pusher 1320, in turn, can be movable through the lumen1382 of the introducer tube 1380. The distal end region of the elongatetubular member for delivering the implant into the eye can be angled,curved, and/or flexible. In some implementations, the introducer tube1380 can have a curved shaped at its distal end region and/or theintroducer tube 1380 can be flexible to conform to a curved shape. Thecurved shape of the distal end region of the introducer tube 1380 canconform to a shape of the desired implantation location, such as thecurvature of the eye near the anterior angle. The outer tube 1318 can bea rigid tube and the introducer tube 1380 can be flexible. The pusher1320 can be a shape-set Nitinol that is takes on the shape of the rigidouter tube 1318 when retracted proximally and allowed to relax back intoits shape-set configuration (i.e. having a curve or bend away from thelongitudinal axis of the outer tube 1318) when extended distally beyondthe distal opening of the outer tube 1318. The introducer tube 1380 canbe flexible enough to take on the shape of the pusher 1320 when thepusher 1320 extends beyond the outer tube 1318. Thus, the introducertube 1380 can be more flexible than the pusher 1320 and the pusher 1320can be more flexible than the outer tube 1318. In some implementations,the introducer tube 1380 can be formed of silicone, thermoplasticelastomer, polyethylene, polypropylene, or a combination thereof. Theintroducer tube 1380 can have a degree of stiffness, but not so stiffthat it is incapable of being retracted over the pusher 1320 duringdeployment.

The introducer tube 1380 and pusher 1320 can work together to deploy thestent 105 in the eye after the stent 105 is cut by the cutter tube 1312.The pusher 1320 can urge the stent 105 out of the lumen 1378 of thecutter tube 1312 into the lumen 1382 of the introducer tube 1380. FIG.24A shows the introducer tube 1380 extending through the lumen 1378 ofthe cutter tube 1312 and extending a distance past the distal end of theouter tube 1318. The stent 105 is positioned within the lumen 1382 ofthe introducer tube 1380 urged distally by the pusher 1320 alsopositioned within the lumen 1382 of the introducer tube 1380. The stent105 is urged distally through the lumen 1382 by the pusher 1320 untilthe stent 105 is positioned within the distal end region of theintroducer tube 1380 (FIG. 24B). At this stage of deployment, the pusher1320 has advanced a distance beyond the distal end of the rigid outertube 1318 such that the pusher 1320 can relax back into its curved orbent shape. The introducer tube 1380, which can be more flexible thanthe pusher 1320, takes on the shape of the pusher 1320. The cut stent105 in this primed position near the distal end of the introducer tube1380 is ready to be implanted in the eye. The introducer tube 1380 canbe retracted while the pusher 1320 remains stationary to effectivelypush the stent 105 out from the lumen of the introducer tube 1380 (seeFIG. 24C).

Advancing the implant from the proximal portion of the instrument caninclude pushing the implant out of the cutting member lumen and into thelumen of the elongate tubular member of the distal portion. The distalportion of the instrument can be positioned adjacent eye tissue toposition the implant in the eye, for example, between the ciliary bodyand the sclera, while the implant remains at least partially inside thelumen of the distal portion of the instrument. The stent 105 can bedeployed from the instrument upon retraction of the introducer tube 1380from the implant while maintaining the implant's position relative tothe adjacent eye tissue. The methods of implantation and delivery of thestent 105 are described in more detail below.

Motion of the cutting and deployment components (e.g., one or more ofthe cutter tube 1312, pusher 1320, introducer tube 1380, and outer tube1318, if present) can be achieved by one or more actuators 1315positioned on one or more regions of the handle 1305. In someimplementations, the one or more actuators 1315 for a first function ofthe delivery device 1110 can be positioned on a first region of thehandle 1305 and one or more actuators 1315 for a second function of thedelivery device 1110 can be positioned on a second region of the handle1305. A first plurality of actuators 1315 can be positioned on a firstregion the handle 1305 to prepare the patch of material 101 into a stentand a second plurality of actuators 1315 can be positioned on a secondregion of the handle 1305 to deploy the stent 105 cut from the patch101. For example, the top region of the handle 1305 can include a firstactuator(s) 1315 for capturing and/or stretching the patch of material101, a second actuator(s) 1315 for moving the cutter tube 1312 to cutthe patch of material 101, and a third actuator(s) 1315 for moving thepusher 1320 to position the cut stent 105 into a primed position fordeployment from the device 1110. A bottom region of the handle 1305 caninclude a fourth actuator(s) 1315 for deploying the stent 105 in theeye.

FIG. 13A shows a top view of an implementation of a delivery device 1110and FIG. 13B shows a bottom view of the device 1110. The top region ofthe handle 1305 can include a first actuator 1315 that is the stretcher1350 for capturing and stretching the patch of material 101 within therecess and another actuator 1315 that is the slider for moving thecutter tube 1312. The bottom region of the handle 1305 can include anactuator 1315 that is the slider for moving the pusher 1320 to push thestent 105 from the outer tube 1318.

FIG. 18A shows a top view of an implementation of the delivery device1110 and FIG. 18B shows a bottom view of the device 1110. The top regionof the handle 1305 can include a first actuator 1315 that is thestretcher 1350 for capturing and stretching the patch of material 101within the recess, a second actuator 1315 that is the slider for movingthe cutter tube 1312, and a third actuator 1315 that is a wheel forincrementally advancing the pusher 1320. The bottom region of the handle1305 can include a fourth actuator 1315 that is a spring retractionbutton for retracting the introducer tube 1380 to release the stent 105from the shaft 1310.

The configuration of the actuators 1315 can vary. For example, theactuators 1315 can include any of a variety of sliders, dials, buttons,knobs, or other type of actuator.

In an implementation, the one or more actuators 1315 configured toaxially move the one or more components of the device can include ascroll wheel 1385 (see FIG. 25). The scroll wheel 1385 may be connectedto a pinion gear 1387 that engages with a corresponding rack gear 1389.Rotation of the pinion gear 1387 may cause the rack gear 1389 to moveaxially and advance or retract any of the axially movable components,such as the pusher 1320 or the cutter tube 1312. FIG. 25 shows the rackgear 1389 attached to the pusher 1320. The scroll wheel 1385 can providemore an incremental, precise motion of the component. A scroll wheeladvancement mechanism is described in U.S. Pat. No. 10,154,924, and isincorporated herein by reference.

In another implementation, the one or more actuators 1315 configured toaxially move the one or more components of the device can include aspring-loaded push button 1390. The introducer tube 1380 can be urged ina distal direction in an extended state relative to the handle 1305,which compresses a front spring 1392 (see FIG. 26). The push button 1390can be held by a latch 1394 in a forward locked position such that thespring 1392 remains compressed during advancement of the stent 105 intothe target location in the eye. Upon applying a downward force on thepush button 1390, the latch 1394 is released allowing the spring 1392 topush the introducer tube 1380 a distance proximally thereby retractingthe introducer tube 1380. Retraction of the introducer tube 1380relative to the pusher 1320 can act to release the implant 105 in theeye. A spring-loaded retraction mechanism is described in U.S. Pat. No.9,241,832, and is incorporated herein by reference.

Activating a first actuator can tension at least a portion of the patchbefore cutting, activating a second actuator can advance the cuttingmember to cut the patch after tensioning, activating a third actuatorcan advance the implant into a deployment position, and activating afourth actuator can deploy the implant from the instrument. Each of theactuators can be operatively coupled to the instrument. It should alsobe appreciated that one or more steps in the cutting and/or deploymentof the implant from the instrument can be combined. For example, a firstactuator can fix, compress, and tension the portion of the patch beforecutting, a second actuator can advance the cutting member and advancethe cut implant into a deployment position, before a third actuatordeploys the implant from the instrument in the eye. Advancing theimplant from the proximal portion of the instrument can include pushingthe implant out of the cutting member lumen and into the lumen of theelongate tubular member of the distal portion.

Advancement of the cutter tube 1312 can cut the stent 105 out from thepatch of material resulting in the stent 105 being positioned within thelumen of the cutter tube 1312. The inner diameter of the cutter tube1312 can be substantially the same as the inner diameter of the outerintroducer tube 1380. The pusher 1320 can be urged distally through thelumen of the cutter tube 1312 urging the cut stent 105 within the lumeninto the lumen of the introducer tube 1380. However, because the cuttertube 1312 and the introducer tube 1380 can be substantially the same intheir inner dimensions, the cutter tube 1312 can be urged backwards bythe introducer tube 1380 as the introducer tube 1380 is urged proximallyby the spring. The stent 105 can be substantially contained within theimplantation conduit and advanced line-to-line within the instrument asit is urged distally. Once the stent 105 is cut from the patch ofmaterial, the pathway of implantation for the stent 105 can include thelumen of the cutter tube 1312, the lumen of the introducer tube 1380 andany other conduit therebetween so that the stent throughout itstransport within the implantation conduit avoids having to transferbetween “gaps” or “edges” in the implantation conduit. The implantationconduit provides a smooth path for deployment of the stent 105 throughthe instrument.

Trephination of tissue and loading of tissue using a delivery device maybe performed simultaneously or sequentially. In a preferredimplementation, the cutting and injecting are integrated. This allowsfor tissue cutting/trephining to be performed in/along the path ofimplantation. The dimensions of the tissue strip are such thatmanipulating it can be difficult. Thus, by integrating the cutting andimplantation, no additional manipulations are necessary. The tissue canbe cut and loaded into a tissue delivery pathway without removing ormanipulating the tissue outside of the cutting device prior to transferinto an intra-ocular applier. The same device can be used to trephinetissue forming the stent and then inject/implant the stent into the eyeenabling a seamless and atraumatic loading of the fine, micro-sizedbiostent tissue without transit manipulation.

The tissue can be, for example, corneal, scleral or other cartilaginoustissue. A section of tissue is cut using the delivery device and/orcutting device. The tissue is loaded into a tissue delivery pathway thatat least partially include the eye without removing the tissuecompletely from the cutting device prior to transfer into anintra-ocular delivery device. In a situation where a single integratedtrephination/injector device is used, that device is used for bothtrephination of tissue as well as injection and implantation of thetissue into the eye.

In another implementation, there is performed simultaneous or sequentialtrephination of tissue and insertion of tissue into the eye. A sectionof tissue is cut and loaded into a tissue delivery pathway. This isperformed using a single device that is configured to trephine tissueand configured to load the trephined tissue into an intra-oculardelivery applier for application of the tissue to the eye.

The applier device can also be used as a delivery device and loadingplatform device or conduit. In such an implantation, the device isconfigured to contain or otherwise house the tissue prior toimplantation. The device permits longitudinal or other directionalmovement of the tissue for implantation into the eye. The device can beconfigured for simultaneous or sequential trephination and applicationloading of the tissue such that, upon completion of a trephination step,the trephined or cut tissue is loaded within a delivery conduit of theapplier device. The trephination device can be coupled to theintraocular delivery device by a coupling or other attachment mechanism,which facilitate tissue transfer into the delivery device.

The stent can be harvested by the trephination device from the patientat the time of surgery. The stent can also be formed from a patch ofmaterial obtained from a donor or other tissue-engineering source. Thepatch of material may be pre-cut into a stent shape and pre-loadedwithin a region of the delivery device. The patch of material may be cutat the time of implantation using a trephination device.

In an implementation, a patch of material 101 may be manually loadedthrough the cut-out windows 326 of the outer tube 318 with the pusher320 in the lumen 328 of the outer tube 318 fully retracted in theproximal position. Once the patch of material 101 is loaded within thedelivery device 110, the shaft 310 and the patch of material 101 may beloaded within a trephination cartridge 205. The cover 314 of thetrephination cartridge 205 can be removed from the base 324 revealingthe recess 321 of the base 324. The shaft 310 of the delivery device 110is positioned within the slots 332, 334 such that the patch of material101 is positioned within the recess 321 therebetween.

The cover 314 of the trephination cartridge 205 is replaced onto thebase 324 compressing and/or tensioning the patch of material 101 withinthe trephination cartridge 205 in the closed configuration. The cuttingmember 312 can be inserted through the bore 338 of the cover 314 urgingthe blades 344 through the cover 314 towards the patch of material 101.The cutting member 312 can be seated within the trephination cartridge205 such that the blades 344 of the cutting member 312 fully slicethrough the patch of material 101. With the blades 344 still in the fullcut position relative to the trephination cartridge 205, the pusher 320is urged distally to prime the shaft 310 and place the now cut stent 105within the lumen of the outer tube 318 towards the opening from thelumen 328 near the distal-most end of the tube 318. The delivery device110 is now ready to be used in a patient.

In an implementation, a patch of material 101 may be loaded within therecess 1321 of a delivery device 1110. The access door 1314 may beopened and the patch of material 101 placed in the recess 1321. The door1314 may be closed thereby capturing and at least partially compressingthe patch of material 101 within the recess 1321. The stretcher 1350 maybe actuated to impart a tension on the patch of material 101 prior tocutting with the cutter tube 1312. The cutter tube 1312 can be actuatedto slide distally thereby cutting the patch of material 101 into a stent105. The pusher 1320 can then be urged distally to prime the shaft 1310by positioning the cut stent 105 within a distal end region of the lumen1382 of the introducer tube 1380. The pusher 1320, once advanced distalto the rigid outer tube 1318, can relax into a curved shape therebyurging the introducer tube 1380 to also take on this curved shape. Thedelivery device 110 is now ready to be used in a patient. The introducertube 1380 may be flexible and/or have a curved shaped at its distal endregion, as discussed above, configured to conform to a shape of thedesired implantation location, such as the curvature of the eye near theanterior angle.

In general, the stent 105 positioned within the shaft of the deliverydevice can be implanted through a clear corneal or scleral incision thatis formed using the delivery device or a device separate from thedelivery device. A viewing lens such as a gonioscopy lens can bepositioned adjacent the cornea. The viewing lens enables viewing ofinternal regions of the eye, such as the scleral spur and scleraljunction, from a location in front of the eye. The viewing lens mayoptionally include one or more guide channels sized to receive the shaftof the delivery device. An endoscope can also be used during delivery toaid in visualization. Ultrasonic guidance can be used as well usinghigh-resolution bio-microscopy, OCT, and the like. Alternatively, asmall endoscope can be inserted through another limbal incision in theeye to image the eye during implantation.

The distal tip of the shaft holding the stent 105 can penetrate throughthe cornea (or sclera) to access the anterior chamber. In this regard,the single incision can be made in the eye, such as within the limbus ofthe cornea. In an embodiment, the incision is very close to the limbus,such as either at the level of the limbus or within 2 mm of the limbusin the clear cornea. The shaft can be used to make the incision or aseparate cutting device can be used. For example, a knife-tipped deviceor diamond knife can be used initially to enter the cornea. A seconddevice with a spatula tip can then be advanced over the knife tipwherein the plane of the spatula is positioned to coincide with thedissection plane.

The corneal incision can have a size that is sufficient to permitpassage of the shaft. In an embodiment, the incision is about 1 mm insize. In another embodiment, the incision is no greater than about 2.85mm in size. In another embodiment, the incision is no greater than about2.85 mm and is greater than about 1.5 mm. It has been observed that anincision of up to 2.85 mm is a self-sealing incision.

After insertion through the incision, the shaft can be advanced into theanterior chamber along a pathway that enables the stent 105 to bedelivered from the anterior chamber into the target location, such asthe supraciliary or suprachoroidal space. With the shaft positioned forapproach, the shaft can be advanced further into the eye such that thedistal-most tip of the shaft penetrates the tissue at the angle of theeye, for example, the iris root or a region of the ciliary body or theiris root part of the ciliary body near its tissue border with thescleral spur.

The scleral spur is an anatomic landmark on the wall of the angle of theeye. The scleral spur is above the level of the iris but below the levelof the trabecular meshwork. In some eyes, the scleral spur can be maskedby the lower band of the pigmented trabecular meshwork and be directlybehind it. The shaft can travel along a pathway that is toward the angleof the eye and the scleral spur such that the shaft passes near thescleral spur on the way to the supraciliary space, but does notnecessarily penetrate the scleral spur during delivery. Rather, theshaft can abut the scleral spur and move downward to dissect the tissueboundary between the sclera and the ciliary body, the dissection entrypoint starting just below the scleral spur near the iris root or theiris root portion of the ciliary body. In another embodiment, thedelivery pathway of the implant intersects the scleral spur.

The shaft can approach the angle of the eye from the same side of theanterior chamber as the deployment location such that the shaft does nothave to be advanced across the iris. Alternately, the shaft can approachthe angle of the eye from across the anterior chamber AC such that theshaft is advanced across the iris and/or the anterior chamber toward theopposite angle of the eye. The shaft can approach the angle of the eyealong a variety of pathways. The shaft does not necessarily cross overthe eye and does not intersect the center axis of the eye. In otherwords, the corneal incision and the location where the stent 105 isimplanted at the angle of the eye can be in the same quadrant whenviewed looking toward the eye along the optical axis. Also, the pathwayof the stent 105 from the corneal incision to the angle of the eye oughtnot to pass through the centerline of the eye to avoid interfering withthe pupil.

The shaft can be continuously advanced into the eye, for exampleapproximately 6 mm. The dissection plane of the shaft can follow thecurve of the inner scleral wall such that the stent 105 mounted in theshaft, for example after penetrating the iris root or the iris rootportion of the ciliary body CB, can bluntly dissect the boundary betweentissue layers of the scleral spur and the ciliary body CB such that adistal region of the stent 105 extends through the supraciliary spaceand then, further on, is positioned between the tissue boundaries of thesclera and the choroid forming the suprachoroidal space.

Once properly positioned, the stent 105 can be released. In someimplementations, the stent 105 can be released by withdrawing the outertube 318 of the shaft 310 while the pusher 320 prevents the stent 105from withdrawing with the outer tube 318. In other implementations, thestent 105 can be released by withdrawing the introducer tube 1380 whilethe pusher 1320 remains stationary, as described elsewhere herein.

Once implanted, the stent 105 forms a fluid communication pathwaybetween the anterior chamber and the target pathway (e.g., supraciliaryspace or suprachoroidal space). As mentioned, the stent 105 is notlimited to being implanted into the suprachoroidal or supraciliaryspace. The stent 105 can be implanted in other locations that providefluid communication between the anterior chamber and locations in theeye, such as Schlemm's canal or a subconjunctival location of the eye.In another implementation, the stent 105 is implanted to form a fluidcommunication pathway between the anterior chamber and the Schlemm'scanal and/or communication pathway between the anterior chamber and asubconjunctival location of the eye. It should be appreciated the devicedescribed herein can also be used to deliver a stent trans-sclerally aswell from an ab interno approach.

As mentioned above, the material used to form the stent can beimpregnated with one or more therapeutic agents for additional treatmentof an eye disease process.

A wide variety of systemic and ocular conditions such as inflammation,infection, cancerous growth, may be prevented or treated using thestents described herein. More specifically, ocular conditions such asglaucoma, proliferative vitreoretinopathy, diabetic retinopathy,uveitis, keratitis, cytomegalovirus retinitis, cystoid macular edema,herpes simplex viral and adenoviral infections can be treated orprevented.

The following classes of drugs could be delivered using the devices ofthe present invention: antiproliferatives, antifibrotics, anesthetics,analgesics, cell transport/mobility impending agents such as colchicine,vincristine, cytochalasin B and related compounds; antiglaucoma drugsincluding beta-blockers such as timolol, betaxolol, atenolol, andprostaglandin analogues such as bimatoprost, travoprost, latanoprostetc; carbonic anhydrase inhibitors such as acetazolamide, methazolamide,dichlorphenamide, diamox; and neuroprotectants such as nimodipine andrelated compounds. Additional examples include antibiotics such astetracycline, chlortetracycline, bacitracin, neomycin, polymyxin,gramicidin, oxytetracycline, chloramphenicol, gentamycin, anderythromycin; antibacterials such as sulfonamides, sulfacetamide,sulfamethizole and sulfisoxazole; anti-fungal agents such asfluconazole, nitrofurazone, amphotericine B, ketoconazole, and relatedcompounds; anti-viral agents such as trifluorothymidine, acyclovir,ganciclovir, DDI, AZT, foscamet, vidarabine, trifluorouridine,idoxuridine, ribavirin, protease inhibitors and anti-cytomegalovirusagents; antiallergenics such as methapyriline; chlorpheniramine,pyrilamine and prophenpyridamine; anti-inflammatories such ashydrocortisone, dexamethasone, fluocinolone, prednisone, prednisolone,methylprednisolone, fluorometholone, betamethasone and triamcinolone;decongestants such as phenylephrine, naphazoline, and tetrahydrazoline;miotics and anti-cholinesterases such as pilocarpine, carbachol,di-isopropyl fluorophosphate, phospholine iodine, and demecariumbromide; mydriatics such as atropine sulfate, cyclopentolate,homatropine, scopolamine, tropicamide, eucatropine; sympathomimeticssuch as epinephrine and vasoconstrictors and vasodilators; Ranibizumab,Bevacizamab, and Triamcinolone.

Non-steroidal anti-inflammatories (NSAIDs) may also be delivered, suchas cyclooxygenase-1 (COX-1) inhibitors (e.g., acetylsalicylic acid, forexample ASPIRIN® from Bayer AG, Leverkusen, Germany; ibuprofen, forexample ADVIL® from Wyeth, Collegeville, Pa.; indomethacin; mefenamicacid), COX-2 inhibitors (CELEBREX® from Pharmacia Corp., Peapack, N.J.;COX-1 inhibitors), including a prodrug Nepafenac®; immunosuppressiveagents, for example Sirolimus (RAPAMUNE®, from Wyeth, Collegeville,Pa.), or matrix metalloproteinase (MMP) inhibitors (e.g., tetracyclineand tetracycline derivatives) that act early within the pathways of aninflammatory response. Anticlotting agents such as heparin,antifibrinogen, fibrinolysin, anti clotting activase, etc., can also bedelivered.

Antidiabetic agents that may be delivered using the present devicesinclude acetohexamide, chlorpropamide, glipizide, glyburide, tolazamide,tolbutamide, insulin, aldose reductase inhibitors, etc. Some examples ofanti-cancer agents include 5-fluorouracil, adriamycin, asparaginase,azacitidine, azathioprine, bleomycin, busulfan, carboplatin, carmustine,chlorambucil, cisplatin, cyclophosphamide, cyclosporine, cytarabine,dacarbazine, dactinomycin, daunorubicin, doxorubicin, estramustine,etoposide, etretinate, filgrastin, floxuridine, fludarabine,fluorouracil, fluoxymesterone, flutamide, goserelin, hydroxyurea,ifosfamide, leuprolide, levami sole, lomustine, nitrogen mustard,melphalan, mercaptopurine, methotrexate, mitomycin, mitotane,pentostatin, pipobroman, plicamycin, procarbazine, sargramostin,streptozocin, tamoxifen, taxol, teniposide, thioguanine, uracil mustard,vinblastine, vincristine and vindesine.

Hormones, peptides, nucleic acids, saccharides, lipids, glycolipids,glycoproteins, and other macromolecules can be delivered using thepresent devices. Examples include: endocrine hormones such as pituitary,insulin, insulin-related growth factor, thyroid, growth hormones; heatshock proteins; immunological response modifiers such as muramyldipeptide, cyclosporins, interferons (including α, β, and γinterferons), interleukin-2, cytokines, FK506 (anepoxy-pyrido-oxaazcyclotricosine-tetrone, also known as Tacrolimus),tumor necrosis factor, pentostatin, thymopentin, transforming factorbeta2, erythropoetin; antineogenesis proteins (e.g., anit VEGF,Interfurons), among others and anticlotting agents includinganticlotting activase. Further examples of macromolecules that can bedelivered include monoclonal antibodies, brain nerve growth factor(BNGF), celiary nerve growth factor (CNGF), vascular endothelial growthfactor (VEGF), and monoclonal antibodies directed against such growthfactors. Additional examples of immunomodulators include tumor necrosisfactor inhibitors such as thalidomide.

In various implementations, description is made with reference to thefigures. However, certain implementations may be practiced without oneor more of these specific details, or in combination with other knownmethods and configurations. In the description, numerous specificdetails are set forth, such as specific configurations, dimensions, andprocesses, in order to provide a thorough understanding of theimplementations. In other instances, well-known processes andmanufacturing techniques have not been described in particular detail inorder to not unnecessarily obscure the description. Reference throughoutthis specification to “one embodiment,” “an embodiment,” “oneimplementation, “an implementation,” or the like, means that aparticular feature, structure, configuration, or characteristicdescribed is included in at least one embodiment or implementation.Thus, the appearance of the phrase “one embodiment,” “an embodiment,”“one implementation, “an implementation,” or the like, in various placesthroughout this specification are not necessarily referring to the sameembodiment or implementation. Furthermore, the particular features,structures, configurations, or characteristics may be combined in anysuitable manner in one or more implementations.

The use of relative terms throughout the description may denote arelative position or direction. For example, “distal” may indicate afirst direction away from a reference point. Similarly, “proximal” mayindicate a location in a second direction opposite to the firstdirection. The reference point used herein may be the operator such thatthe terms “proximal” and “distal” are in reference to an operator usingthe device. A region of the device that is closer to an operator may bedescribed herein as “proximal” and a region of the device that isfurther away from an operator may be described herein as “distal”.Similarly, the terms “proximal” and “distal” may also be used herein torefer to anatomical locations of a patient from the perspective of anoperator or from the perspective of an entry point or along a path ofinsertion from the entry point of the system. As such, a location thatis proximal may mean a location in the patient that is closer to anentry point of the device along a path of insertion towards a target anda location that is distal may mean a location in a patient that isfurther away from an entry point of the device along a path of insertiontowards the target location. However, such terms are provided toestablish relative frames of reference, and are not intended to limitthe use or orientation of the devices to a specific configurationdescribed in the various implementations.

While this specification contains many specifics, these should not beconstrued as limitations on the scope of what is claimed or of what maybe claimed, but rather as descriptions of features specific toparticular embodiments. Certain features that are described in thisspecification in the context of separate embodiments can also beimplemented in combination in a single embodiment. Conversely, variousfeatures that are described in the context of a single embodiment canalso be implemented in multiple embodiments separately or in anysuitable sub-combination. Moreover, although features may be describedabove as acting in certain combinations and even initially claimed assuch, one or more features from a claimed combination can in some casesbe excised from the combination, and the claimed combination may bedirected to a sub-combination or a variation of a sub-combination.Similarly, while operations are depicted in the drawings in a particularorder, this should not be understood as requiring that such operationsbe performed in the particular order shown or in sequential order, orthat all illustrated operations be performed, to achieve desirableresults. Only a few examples and implementations are disclosed.Variations, modifications and enhancements to the described examples andimplementations and other implementations may be made based on what isdisclosed.

In the descriptions above and in the claims, phrases such as “at leastone of” or “one or more of” may occur followed by a conjunctive list ofelements or features. The term “and/or” may also occur in a list of twoor more elements or features. Unless otherwise implicitly or explicitlycontradicted by the context in which it is used, such a phrase isintended to mean any of the listed elements or features individually orany of the recited elements or features in combination with any of theother recited elements or features. For example, the phrases “at leastone of A and B;” “one or more of A and B;” and “A and/or B” are eachintended to mean “A alone, B alone, or A and B together.” A similarinterpretation is also intended for lists including three or more items.For example, the phrases “at least one of A, B, and C;” “one or more ofA, B, and C;” and “A, B, and/or C” are each intended to mean “A alone, Balone, C alone, A and B together, A and C together, B and C together, orA and B and C together.”

Use of the term “based on,” above and in the claims is intended to mean,“based at least in part on,” such that an unrecited feature or elementis also permissible.

The systems disclosed herein may be packaged together in a singlepackage. The finished package would be sterilized using sterilizationmethods such as Ethylene oxide or radiation and labeled and boxed.Instructions for use may also be provided in-box or through an internetlink printed on the label.

The invention claimed is:
 1. A method of preparing an implant forimplantation into, and of inserting the implant into, an eye of apatient, the method comprising: inserting a patch of a material into aproximal portion of an instrument, the instrument further comprising acutting member and a distal portion sized for insertion into an eye;cutting the patch with the cutting member to form the implant; advancingthe implant from the proximal portion of the instrument into adeployment position in a lumen of an elongate tubular member of thedistal portion; inserting the distal portion of the instrument into theanterior chamber of the eye; positioning the distal portion adjacent eyetissue; and deploying the implant from the instrument.
 2. The method ofclaim 1, wherein the inserting the patch of the material comprisesinserting the patch into a recess in the proximal portion and closing acover over the recess.
 3. The method of claim 2, wherein the cover isadapted to engage at least some portion of the patch of the materialbefore the cutting.
 4. The method of claim 2, wherein at least a portionof the cover is transparent.
 5. The method of claim 2, wherein the coverprevents movement of the patch during the cutting of the patch with thecutting member.
 6. The method of claim 1, further comprising tensioningat least a portion of the patch of the material before cutting thepatch.
 7. The method of claim 6, wherein the tensioning the portion ofthe patch comprises compressing a first portion and a second portion ofthe patch and tensioning a central portion of the patch, the centralportion located between the first and second portions.
 8. The method ofclaim 7, wherein the central portion of the patch comprises the implantupon the cutting the patch with the cutting member.
 9. The method ofclaim 6, wherein the tensioning the portion of the patch comprisesactivating an actuator to tension the portion of the patch.
 10. Themethod of claim 9, wherein the activating an actuator comprises rotatingthe actuator to tension the portion of the patch.
 11. The method ofclaim 3, wherein the cover comprises an actuator, and wherein actuationof the actuator tensions at least a portion of the patch.
 12. The methodof claim 1, further comprising inserting the distal portion of theinstrument ab interno into the anterior chamber through a cornealincision, while the proximal portion of the instrument remains outsidethe eye.
 13. The method of claim 1, wherein the material comprisesbiologically-derived material suitable for implantation into the eye.14. The method of claim 13, wherein the biologically-derived materialcomprises tissue harvested from a donor or from the patient, orautograft, allograft, or xenograft material.
 15. The method of claim 1,wherein the material comprises an engineered or 3D-printed materialsuitable for implantation.
 16. The method of claim 1, wherein theimplant comprises one or more therapeutic agents.
 17. The method ofclaim 1, wherein the deploying the implant from the instrument resultsin the implant residing at least in part between a ciliary body andsclera of the eye of the patient.
 18. The method of claim 17, whereinthe implant resides between the ciliary body and sclera within acyclodialysis cleft.
 19. The method of claim 1, wherein the cuttingmember comprises a cutting member lumen, a distal opening and a pair ofopposed cutting edges, and wherein the cutting comprises advancing thecutting member to cut the patch of the material and capturing theimplant within the cutting member lumen.
 20. The method of claim 19,wherein the pair of opposed cutting edges cut the patch in two locationsto separate the implant from a remainder of the patch.
 21. The method ofclaim 19, wherein an internal diameter of the elongate tubular member issubstantially the same as an internal diameter of the cutting memberlumen.
 22. The method of claim 19, wherein a distal portion of thecutting member is beveled.
 23. The method of claim 1, wherein theimplant comprises a longitudinal axis and wherein the longitudinal axisof the implant remains aligned with a longitudinal axis of the lumen ofthe elongate tubular member as the cutting member finishes cutting thepatch to form the implant.
 24. The method of claim 19, wherein theadvancing the implant from the proximal portion of the instrumentcomprises pushing the implant out of the cutting member lumen and intothe lumen of the elongate tubular member of the distal portion.
 25. Themethod of claim 1, wherein a distal end region of the elongate tubularmember is at least one of angled or curved or flexible.
 26. The methodof claim 1, wherein the method further comprises: activating a firstactuator to tension at least a portion of the patch before the cutting;activating a second actuator to advance the cutting member to cut thepatch after the tensioning; activating a third actuator to advance theimplant into the deployment position; and activating a fourth actuatorto deploy the implant from the instrument, wherein each of the actuatorsis operatively coupled to the instrument.
 27. The method of claim 1,wherein the positioning the distal portion adjacent eye tissue comprisespositioning the implant between the ciliary body and sclera while theimplant remains at least partially inside the lumen of the distalportion.
 28. The method of claim 1, wherein the deploying the implantfrom the instrument comprises retracting the elongate tubular portionfrom the implant while maintaining the implant's position relative tothe adjacent eye tissue.
 29. The method of claim 1, wherein adistal-most tip of the elongate tubular member is blunt to allow fordissecting the eye tissue without cutting the eye tissue.
 30. The methodof claim 2, wherein the closing the cover over the recess comprisesengaging a portion of the cover with a first portion of the patch tocompress the first portion of the patch and to tension a second portionof the patch.